MedicalForumWA 0917 Public Edition

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Improving Breathing Coping with Fear Dollars and Sense Blood on Track

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EDITORIAL

‘It’s the breach of trust that cheeses everyone off…’

As professionals we expect the best of people but become actively disappointed when they don’t do the right thing. We believe that almost anyone can reform.

The harsh reality may be otherwise. Many say nonreformers need to be banished from society if they commit crimes that don’t rest easy with the majority.

But first, perhaps they need to be confronted when they do wrong and have a chance to reform. The alternative may be for accomplices to hide them away and perhaps allow their crimes to be repeated.

system in place, patients and trainee doctors are more easily exploited by abuse of trust and power. Sexual harassment may be influenced by cultural differences but it is for the majority to decide if criminals hide as doctors.

We may say the culture of medicine has encouraged misbehaviour. The silent non-offending majority may disagree even when offenders may have been upright champions of some folk. It’s not simple by any means, which is why we need people without fear or favour running things, not those who can be perceived as accomplices.

Why do we say doctors shouldn’t be mandatorily reported for serious misdemeanours? We offer abused children the protection of mandatory reporting.

We argue it might stop doctors seeking help so instead of a ‘blame and shame’ approach, we counsel wrongdoers. I can see the logic in this but it depends on what sort of people we have in charge and the seriousness of the misdemeanours. Those in charge need to be transparent and accountable otherwise they may be viewed as little more than accomplices.

People in positions of trust have attracted non-reformers at best and criminals at worst. It is time to recognise that the church brand is morally bankrupt and perhaps do something about it. Doctors can topple into the same quagmire pretty easily unless we extrapolate the lessons learnt.

In consumers’ eyes, doctors have feet of clay and if churches can get it very wrong, then other caring professions can also breach trust. That’s the sad reality.

In fact, on reflection, it’s the breach of trust that cheeses everyone off, particularly among those protectors of vulnerable souls who need it most.

Medicines Australia is coming clean and can do more, medical equipment manufacturers should come under a similar Code of Practice, and whistleblowers in the public sector need better protection. A philosophical shift within the profession, which is inherently conservative, is overdue and is coming.

As a caring profession, it is our care of people that must shine supreme, more than the mighty dollar.

I

n this edition, focused on Respiratory Health, we learn that: correct use of inhalers may be all that is needed; the most common low-survival cancer is lung cancer; catastrophising with kids may not be doing anxious parents a favour; blood eosinophilia might help pick those with COPD who would benefit from ICS; cow’s milk protein allergy in kids has many faces; patient education may be the crucial part of respiratory treatment; the poor prognosis of Idiopathic Pulmonary Fibrosis has recently changed; and watchful waiting rather than tonsillectomy in kids has particular selection criteria.

Content of this edition shows that many people stand ready to care for people, while some feel under financial and other pressures.

All in all, an enthralling mix of helpful opinion.

Unless the profession puts a robust, transparent protective

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MEDICAL FORUM

EDITORIAL TEAM Managing Editor Ms Jan Hallam (0430 322 066) editor@mforum.com.au Medical Editor Dr Rob McEvoy (0411 380 937) rob@mforum.com.au

Clinical Services Directory Editor Ms Jenny Heyden (0403 350 810) jen@mforum.com.au Journalist Mr Peter McClelland journalist@mforum.com.au

Supporting Clinical Editor Dr Joe Kosterich (0417 998 697) joe@mforum.com.au GRAPHIC DESIGN Thinking Hats hats@thinkinghats.net.au

SEPTEMBER 2017 | 1

CONTENTS SepTember 2017

16

12 FEATURES 12 Spotlight: Force’s Matt Hodgson 14 Close-Up: Prof Anna Nowak 16 Patient Blood Management 46 Heart of the Congo Dr Carol McGrath NEWS & VIEWS 1 Editorial: Breach of Trust

4

6 6 10 11 21 24

Dr Rob McEvoy Letters to the Editor Doctors Aren’t Easily Bought Mr Milton Catelin Push For Assisted Dying Bill Dr Alida Lancee Hospital Trash is Another’s Treasure Dr Rob Davies NMHS Response GPs in the ED Curious Conversation: Dr Megan Pilkington Have You Heard?

Beneath the Drapes Conquering Cancer Fears Not-so-Super Advice Mr David Huggins

14

46 25

Data Breaches

Mr Jerome Chiew 31 Spotlight on Injured Workers

Mr Stephen Psaila-Savona

Lifestyle 49 Wine Review: Millbrook and Deep Woods

Dr Craig Drummond

50 Doctor in the Arts: Dr Robert Edeson 51 Love Songs: Paul Gabrowsky & Kate Ceberano 52 Theatre: I Am My Own Wife 52 Wine Winner: Dr Rose Schuddinh 53 Competitions 54 My Local: Duck Duck Bruce Café 54 Funny Side

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MEDICAL FORUM

clinicals

5

Rapid Respiratory Diagnosis Dr Miles Beaman

33

Drug Treatment of Stable COPD C/Prof Alan James

Saving Sight in Bali

35

Improving Inhaler Technique Ms Louise Papps

37

Tonsillectomy in Kids Dr George Sim

39

Iatrogenic Perinatal Anxiety Dr Leon Levitt

41

Breathing Problems Case Study Dr Michael Prichard

43

Cow’s Milk Allergy in Babies Dr Christiane Remke

45

IPF Game Changers Dr Sina Keihani

World Sight Day in Bali in October is expected to be busy but satisfying for all the volunteers of the John Fawcett Foundation.

See Page 22

guest columns

8

What My Patients Teach Me Dr Nick Lan

18

NDIS: Complexity & Uncertainty Prof David Gilchrist

19

WAMAS Lives to Fight On Dr Mark Hanikeri

28

Value Does Have a Price Dr Rohan Gay

INDEPENDENT ADVISORY PANEL for Medical Forum John Alvarez (Cardiothoracic Surgeon), Peter Bray (Vascular Surgeon), Chris Etherton-Beer (Geriatrician & Clinical Pharmacologist), Joe Cardaci (Nuclear & General Medicine), Alistair Vickery (General Practitioner: Academic), Philip Green (General Practitioner: Rural), Mark Hands (Cardiologist), Pip Brennan (Consumer Advocate), Olga Ward (General Practitioner: Procedural), Piers Yates (Orthopaedic Surgeon), Stephan Millett (Ethicist), Kenji So (Gastroenterologist) Astrid Arellano (Infectious Disease Physician) MEDICAL FORUM SEPTEMBER 2017 | 3

LETTERS To THE EDITOR Doctors aren’t easily bought Dear Editor, Your correspondent asks whether transparency should be expected from our public officials (August edition editorial). She draws doctors into this equation because they interact with the public. Transparency is a positive pursuit that adds useful information to improve a health care professional’s understanding of the treatments they prescribe.

What a great thing then that pharmaceutical companies have a rigorous code of conduct around their involvement with doctors – one that was not ‘ordered’ by the ACCC, but they have authorised and supports. The AMA fully supports these transparency measures too. In a recent article AMA Vice President Dr Tony Bartone said he “didn’t believe that in Australia there was any adverse impact on prescribing behaviour arising from pharmaceutical company payments or educational events.”

All MA members participate in the Code of Conduct and report on when they support doctors attending educational meetings and symposia, whether organised by companies or by another organisation. If a doctor does not want the general public to know about what support they’re receiving from a MA member, then they can’t receive support – it’s that simple.

Our Code of Conduct was one of the first to introduce these measures worldwide and many other countries have since introduced similar measures. The latest transparency measures – Edition 18 of the Code – reflects a global trend to be open and transparent about interactions with medical professionals.

Support provided to healthcare professionals is consistent with what’s needed to attend a meeting and reflects fair remuneration of speakers.

We believe, and as you’ve reiterated in your article (75% thought educational events sponsored by pharma were needed by the profession), these meetings play an important role in ensuring health care professionals can learn the latest in cutting-edge medicines and clinical treatment, which can only benefit Australian patients.

After all, shouldn’t doctors who prescribe

SYNDICATION AND REPRODUCTION Contributors should be aware the publishers assert the right to syndicate material appearing in Medical Forum on the MedicalHub.com.au website. Contributors who wish to reproduce any material as it appears in Medical Forum must contact the publishers for copyright permission.

DISCLAIMER Medical Forum is published by HealthBooks as an independent publication for the medical profession in Western Australia.

4 | SEPTEMBER 2017

medicines have the latest information about how they should be administered?

Since the time of the Ancient Greeks and the Hippocratic Oath, physicians have been guided by a high standard of ethics which they hold dear. The oath requires a doctor to put the patient first using their training and expertise to administer the most appropriate treatment and, importantly, to cause no harm.

It’s illogical to think that some sushi or a symposium will trump a doctor’s experience and education, or influence them into prescribing something that was not in the best interests of their patient.

Mr Milton Catelin, Chief Executive, Medicines Australia ........................................................................

Push for assisted dying bill Dear Editor, Despite advances in medical care, many people still face a protracted and miserable dying experience. Palliative care experts agree that despite their efforts, a small percentage of terminally ill patients continue to suffer from poorly controlled symptoms.

The current law fails those patients in regard to end-of-life care choices.

Anonymous surveys indicate that 25% of Australian doctors who provide end-of-life care have provided potentially life shortening treatments to end their patients suffering.

They could face a murder charge. The legality is dependent on the unquantifiable intent of the doctor to relieve suffering or hasten the person’s death.

Some tiptoe around the law and call their care ‘Terminal Sedation’. This is a form of slow assisted dying.

Late 2016, Victorian Civil and Administrative Tribunal concluded that Dr Rodney Syme’s prescription of Nembutal was good palliative care by reducing a patient’s fear of having to endure intolerable suffering whilst dying.

An assisted dying law would provide clarity, transparency, universal availability and, above all, autonomy over end-of-life care choices for the dying. The majority of doctors support such a law as do over 80% of the public.

The support of all advertisers, sponsors and contributors is welcome.

Neither the publisher nor any of its servants will have any liability for the information or advice contained in Medical Forum. The statements or opinions expressed in the magazine reflect the views of the authors.

Readers should independently verify information or advice. Publication of an advertisement or clinical column does not imply endorsement by the publisher or its contributors for the promoted product, service or treatment.

The WA Government has started a Parliamentary Inquiry for an Assisted Dying Bill based on the Oregon model, which has been in effect for over 20 years with none of the problems often feared by opponents.

Doctors for Assisted Dying Choice will provide medical input to ensure this Bill will be workable with appropriate safeguards.

As doctors, we can stand up for those who cannot, the dying.

To show support and remain up to date please join the group at http://drs4assisteddyingchoice.org/ Excellent balanced information is summarised in the Victorian Parliamentary Inquiry into End-of-Life care Choices on www.parliament.vic.gov.au/lsic/inquiry/402 Dr Alida Lancee, Western Australian Convenor, Doctors for Assisted Dying Choice ........................................................................

Hospital trash is another’s treasure Dear Editor, The obscenity of the waste generated in our hospitals (July, War on Waste, and August, Separate Hospital Waste) is surpassed by a Sir Charles Gairdner Hospital bureaucracy that recently refused to donate unused expired medical equipment to those of us involved in overseas medical and surgical aid projects.

Newborn babies in Cambodia are being wrapped in newspaper while Sir Charles Gairdner Hospital sends unused sterile but expired cloths and other perfectly useable medical disposables to landfill, claiming that this is Health Department of WA policy.

Dr Robert Davies, Urological Surgeon, West Leederville

Response Western Australian hospitals have donated many pieces of medical equipment such as crutches, dressing trolleys, hospital beds, walking frames and operating tables to various countries, including Tanzania, Kenya, Zambia, Sudan, Ethiopia and Somaliland. continued on Page 6

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EDITORIAL POLICY This publication protects and maintains its editorial independence from all sponsors or advertisers.

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MEDICAL FORUM

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Rapid Respiratory Diagnosis

Prof Miles H Beaman FRACP, FRCPA, FACTM

About the Author Respiratory Infections are the commonest cause of infectious mortality worldwide, accounting for over 4 million deaths/year 1.

Recent studies suggest about 260,000 cases/year occur in the UK with 32% requiring hospitalisation and generate £440 million/year in associated health costs.

Classical lobar community-acquired pneumonia is usually due to pyogenic bacteria such as Streptococcus pneumoniae, Haemophilus influenza and less-commonly Enterobacteriaceae. Empiric treatment protocols2 are targeted at these pathogens and traditional microbiological methods culturing blood and sputum regularly identify the pathogen and give sensitivity data which may modify the original regimen.

Atypical pneumonia syndromes are caused by noncultivatable or difficult-to-culture organisms and often cause mild to moderate disease, particularly in older children and young adults (i.e. Mycoplasma pneumoniae and Chlamydophila pneumoniae-ATY panel).

Traditionally these have been identified by serology, but the sensitivity of this method is not high and delayed seroconversion is common. Other atypical pathogens can cause more severe disease with high mortality (Legionella pneumophila, Legionella longbeachae and Pneumocystis jiroveci), so rapid diagnosis with PCR (ATY panel) is essential to guide timely therapy with macrolide agents (erythromycin, azithromycin, clarithromycin) or anti-folate agents in the case of the latter pathogen.

Prolonged-cough syndromes (i.e. longer than two weeks) require exclusion of whooping cough (using PCR assays for Bordetella pertussis and Bordetella parapertussis, BPP panel) as well as non-pertussis viral causes which can be detected by our respiratory viral PCR panel (RES- Influenza A and B, Respiratory Syncitial virus, Parainfluenza1-3, Respiratory Adenovirus, human Metapneumovirus).

In pertussis a positive PCR result correlates with infectivity and clinical response to macrolides. Many patients present after this

period (later than 3 weeks) but household contacts are at high risk of acquisition of disease, so we recommend collecting a nasopharyngeal aspirate to enable detection of Bordetella pertussis–specific mucosal IgA which can identify households at risk of a propagating mini-epidemic (in the last 1925 cases of notified pertussis at WDP, PCR was positive in only 52.5% of cases whereas mucosal IgA identified 69.7% of cases)3.

Influenza epidemics are also important causes of mortality, especially in elderly and otherwise high risk patients (pregnant women, chronic respiratory or cardiac disease, obesity or diabetes) and can be rapidly detected by our respiratory viral PCR panel4, which also identifies other viruses which do not need continued antiviral therapy or triage (i.e. Parainfluenza1-3, Respiratory Adenovirus, human Metapneumovirus).

Because the Medicare Schedule only reimburses testing for three pathogens, it is important that requesting Doctors choose the appropriate PCR panel for the patient’s symptoms. A syndromic approach in ordering is recommended. Most PCR tests are run six times a week, and can give a rapid aetiological diagnosis.

Prof Beaman graduated from the UWA and trained in Clinical Microbiology and Infectious Diseases at Sir Charles Gairdner Hospital, making him the most experienced Infectious Disease Physician in WA. He completed a Post Doctoral Fellowship at Stanford University and then established the first Infectious Diseases Department in Western Australia at Fremantle Hospital.

He joined Western Diagnostic Pathology in 2002, where he is Medical Director and Deputy CEO. He is also a Clinical Professor at both the University of Western Australia and University of Notre Dame Australia.

Recommended Syndromic PCR Test Ordering: • URTI, flu-like symptoms (Fever, respiratory symptoms, myalgia/fatigue)- respiratory virus PCR (RES panel) • Cough, LRTI signs without consolidationatypical respiratory pathogen PCR (ATY) • Prolonged cough syndromenasopharyngeal aspirate for Bordetella pertussis and B. parapertussis PCR and specific mucosal IgA assay.

Take Home Points • Respiratory Infections remain a major cause of morbidity and mortality worldwide.

• Classical microbiology is reliable, but may take 48-72 hours for useful results to guide clinical management.

• Western Diagnostic Pathology offering a number of molecular testing panels which greatly speed up diagnosis of respiratory syndromes (ATY, BPP, RES panels).

• Medicare Schedule restrictions mandate careful selection of the most appropriate PCR panel, which can be facilitated by a syndromic approach to test ordering References 1. Guerrant RL. Threats to global health and survival: the growing crises of tropical infectious diseases-our “unfinished agenda”. Clin Infect Dis 1999:28;966-86 2. Therapeutic Guidelines: Antibiotic. Version 15, 2015. Respiratory Tract infections: pneumonia.

3. Miles H Beaman, Mahdad Karimi, Meredith Hodge, Anthony D Keil, Peter Campbell. Contribution of Nasopharyngeal IgA and Polymerase Chain Reaction testing to diagnosis of laboratory-notified Pertussis in Australian community specimens. Eur J Microbiol Immunol (Bp). 2014 Dec;4(4):177-83.

4. Beaman MH and Leung M. Pandemic Influenza testing at the coalface. Med J Aust 2010:192;102-4.

General Enquiries: Ph (08) 9317 0999 Email: admin@wdp.com.au Website: www.wdp.com.au Results Enquiries: Ph 136 199 For a list of Collection Centres and Laboratories go to www.wdp.com.au

MEDICAL FORUM

SEPTEMBER 2017 | 5

LETTERS To THE EDITOR continued from Page 4 Following decommissioning of the Swan District Hospital in late 2015 the North Metropolitan Health Service (NMHS) donated a significant amount of medical equipment and furniture to the ‘Health Hope Zambia’ and other charity groups.

NMHS remains supportive of such initiatives

and is currently exploring avenues of support for the Nokor Tep Women’s Hospital in Cambodia, following a request from the Nokor Tep Foundation in Cambodia to Sir Charles Gairdner Hospital.

once outside the use by dates. The Health Service has a duty of care to dispose of these products appropriately. To allow others to use items that we, ourselves, do not allow for safety reasons would breach that duty.

Unused sterile expired cloths and medical disposables are considered to be unsafe

NMHS spokesperson

Can GPs Sort Out EDs? Health Department of WA-funded research by the Division of General Practice at UWA’s Faculty of Health and Medical Sciences may offer vital data which could help address the growing overcrowding problems in the state’s emergency departments.

The trial has been completed with 15 GPs of varying levels of experience spending 2-3 sessions over several months in four emergency departments, interviewing patients who had presented to ED but were not admitted to hospital, to determine if the GP thought they could have managed the presentation in general practice.

“Across WA, approximately 60% of people who present to ED are sent home after being managed. While there has been quite a bit of work done previously in this area, assessments to determine if presentations were primary care types were made by emergency physicians and triage urgency level. We thought it was important to study if a GP assessment could better determine the overall burden of primary care type ED presentations,” said Study leader A/Prof Alistair Vickery.

GPs, after conducting 15-minute GP-type consults with patients, had to determine one of three responses: • This person needed to come to ED, I couldn’t have treated them • I could have treated this case in general practice • If I had extra resources and/or training, I could have treated them in general practice.

so we really didn’t know how representative our sample was of the total group of patients presenting.”

“We didn’t ask why people were coming to ED because that is a different question loaded with a complex range of health service, sociological and cultural issues,” Alistair said.

Perhaps being free, easily recognisable, open 24 hours a day and a one-stop shop are a few compelling reasons.

The study team made some interesting observations along the way.

“ED overcrowding has been an area of interest for a very long time and all sorts of policies and processes have been tried but without evidence of effectiveness,” he said.

“For instance there was some concern around the AIHW’s classifications of triage level 4 and 5 (non-urgent) being thought of as Primary Care type ED presentations.

However, clinicians recognise that urgency doesn’t necessarily reflect complexity of presentation. And equally there are some triage 2-3 presentations, while urgent, were relatively simple and could have been treated in general practice.”

“So triage levels have been found not to be a good definition of a primary care presentation.”

Researchers also had to take into account the potential bias in their patient sample.

“We had a small sample for practical logistic reasons and that subjects our sample to bias. ED physicians assessed whether patients were to be discharged and the GPs were opportunistically interviewing them,

“We have recently received the linked data from the WA data collection to give us a clearer idea of what the GPs did and didn’t see which will allow us to assess that bias.”

There is considerable interest in the study because this is the first time anywhere as far as the researchers could tell, that GPs had made an assessment of ED presentations and attempted to answer the critical question, ‘how many patients presenting to ED could have been treated in general practice’.

There are a lot of questions still to answer regardless of the outcomes of the study. If it finds that GPs could handle a significant number of ED presentations, the milliondollar question arises, how can that be achieved?

Co-located GP clinics have failed to make inroads into ED overcrowding, and the issue of continuity of care remains a critical one, particularly with the rise and rise of chronic conditions.

If it comes down to cost, as so many things do these days, is the community getting a good bang for its buck with a quick fix ED presentation? How much would it cost to create a health system where primary and tertiary care co-operate to provide the right care in the right place?

Perhaps the answers start when there is good data on how many patients who go to ED are GP type patients.

By Jan Hallam

CURIOUS CONVERSATIONS

Life is an Adventure Dr Megan Pilkington loves being a GP, and has a pretty good time sans stethoscope as well.

If I could spend a year working overseas I’d go to… Canada, because I love hiking and skiing. It would be great to have the opportunity to travel around such a beautiful country, between work commitments, of course!

One of the most moving films I’ve ever seen is… a close tie between Lion and Red Dog because I've never managed to keep my eyes dry in either film. In Lion, the original footage of Saroo's reunion with his mother is something really special.

6 | SEPTEMBER 2017

Being a GP is both challenging and rewarding because… as the saying goes you’re a ‘jack of all trades and master of none.’ That's the challenging part! The diversity of General Practice would be the most rewarding aspect, and the opportunity to form meaningful relationships with patients and their families.

If I had to sum up my medical training in two sentences I’d say… it's been an adventure that's for sure! Medicine has taken me to some remote and beautiful parts of Australia and I feel incredibly lucky to have worked with some truly amazing people along the way – both patients and colleagues.

MEDICAL FORUM

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INCISIONS

What My Patients Teach Me This year I have been heavily involved in the care of two patients aged in their 20s, both with stage IV cancer. Seeing these young patients with terminal illnesses has impacted on how I treat patients (Patient One) and my own outlook on life (Patient Two).

Patient One was diagnosed with an extremely rare metastatic carcinoma. I was there when she was first diagnosed and when she died – all within my oncology registrar rotation. I saw the disease progress rapidly on her scans, despite chemotherapy. I witnessed her strong resolve to do whatever it took to stay alive.

The impact of patients?

Treating Patient One caused me to reflect heavily on the ethical principles of patient care. As the registrar under an oncologist, I was initially not involved in making treatment decisions and, hence, safeguarded from that element. However, her treating oncologist was away when she was admitted to hospital with increasing cancer pain and I found myself having to make many treatment decisions.

We sequenced her whole genome, looking for targetable gene mutations but found none. We discussed her case with experts around the world, hoping for other treatment options, but were disappointed.

During the last few weeks of her life, she requested to fly across Australia to participate in a research study trialing new immunotherapy drugs as a last-resort treatment for endstage cancers with no targetable mutations. She ended up enrolling in the study but died shortly after returning to Perth for more chemotherapy.

Patient Two was also diagnosed with an aggressive sarcoma. I was the cardiology registrar when he was referred to me late at night. I went to the ED and found a fit young man smiling cheerfully at me with his father by his side. He was a hard-working university student, a non-drinker and a non-smoker. He reminded me of myself, and that was scary. He seemed fine except his heart rate was between 130 and 160, in atrial flutter. I tried medications to decrease his heart rate but that only lowered his blood pressure. A brief echocardiogram showed a massive pericardial effusion and a mass in his myocardium. I admitted him immediately to the CCU and he underwent insertion of a pericardial drain. Despite having a terminal diagnosis, he remained positive and never complained.

My strong emotional investment in their stories and my lack of experience to guide their decision making were weighty issues.

8 | SEPTEMBER 2017

Yet this patient wanted to live. Shouldn’t we at least let her try other options? Whatever we were doing now clearly wasn't working.

As doctors, we should give our medical opinion and allow the patient to decide on the treatment plan. In the end, I complied with her wishes and organised her enrolment in the research trial. To this day I still question whether it was the right thing to do.

Patient Two was the reverse. If he was angry about his situation, I couldn’t tell. He did what we advised and never complained. I was deeply sorry for him and his family and everyone on his care team felt the same way. We knew he was scared and, although he never expressed it, we knew he didn’t want to give up either.

His case illustrated to me how fragile life can be and how it can change in a moment. It made me contemplate the most important things in my life and how I should be spending my time.

She made it clear to me that she wanted all treatment avenues explored. I spent hours each day liaising with genetic specialists and oncologists around Australia and America. It didn't seem fair to me that someone so young must die of a rare cancer. I wanted to do everything I could, as her doctor, to help her. I was of a similar age and knew there was still so much life to be lived. If I were in her position, I would want to try any treatment option.

When she requested to go interstate for the trial, she already had widespread metastatic disease. Her risk of pulmonary embolism was high and her condition was deteriorating quickly. Furthermore, her coagulation profile was becoming deranged. The risks of the liver biopsy were substantially increased. She still wanted to go. Her mother still wanted her to go.

I distinctly remember the moment she told me that she “was not going to give up”.

Logically, there seemed no point in going.

What was the point of spending your last few weeks on earth travelling to a different city in discomfort, to have a risky biopsy with little hope of treatment? We are taught to do no harm. Would me encouraging this trip constitute harm? Would entering the trial benefit the patient? Should such a sick person even be enrolled into a clinical trial?

Life and death is something that we deal with every day in our profession.

We don’t learn much about it in medical school, we kind of just get used to it from the job. Being a doctor can be emotionally taxing. This case served to remind me not to become too attached to patients.

Impact on my professionalism?

Both cases have encouraged a deep reflection on the ethical issues in medicine and about the ethical framework in clinical practice. It has taught me the importance of meaningful communication to engage with patients, to be respectful of their rights and to empower them to make decisions about their own lives.

I discovered empathy and my desire to help others. However, I also discovered that I have a way to go. My strong emotional investment in their stories and my lack of experience to guide their decision making were weighty issues. I believe that only time and experience will help improve my skills in this area.

… this patient wanted to live. Shouldn’t we at least let her try other options?

Whatever we were doing now clearly wasn't working.

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Dr Nick Lan is a doctor-in-training at FSH who was asked by his clinical supervisor for a short reflection on his encounters with two terminally ill patients. His insights are pertinent.

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MEDICAL FORUM

SEPTEMBER 2017 | 9

HAVE YOU HEARD?

Perinatal anxiety can kill

Kids and depression While talking about vulnerable populations, last issue we looked into the Origins Project being run by the Telethon Kids Institute and Joondalup Health Campus. One of the project leads, paediatrician Dr Desiree Silva, told Medical Forum that she was seeing children as young as seven expressing suicidal thoughts. Australian Rotary Health has invited psychiatrist Prof Michael Sawyer, from the University of Adelaide, neuropsychiatric epidemiologist Prof Vera Morgan and eating disorders expert A/Prof Susan Byrne, both from UWA, to speak at a forum, Lifting the Lid: Mental Health and Our Kids, at 6pm September 13 at the University Club at UWA. www.australianrotaryhealth.or.au/events

PAYG med school As WA’s three medical schools head towards final exams for the year, including Curtin Medical School in its inaugural year, there’s upset and controversy on the other side of the country with Macquarie University preparing to accept its first cohort of full fee-paying students in 2018. Domestic students will pay

Last month we reported that a class action had begun in Sydney against Johnson & Johnson, the manufacturer of transvaginal mesh. Now the TGA has said it will follow a decision by the European Commission to implement a number of medical device reforms, including to ‘up-classify’ all surgical mesh medical devices (such as gynaecological mesh) to Class III (high risk) and to provide patient implant cards and consumer product information for all implantable medical devices. The TGA has released a consultation paper regarding its decision to reclassify all implantable surgical mesh medical devices and is looking for views from industry, healthcare professionals, and current and future recipients of medical devices on the proposed implementation of these changes.

informed consent. Dr McWhirter, who works at the Menzies Institute for Medical Research and the University of Tasmania’s Centre for Law and Genetics, said currently there was no general duty to disclose performance data, but there could be in the future. A spokesperson for the Royal Australasian College of Surgeons (RACS) said that there had been little advance on the legal duty to disclose performance data since the Chappel v Hart test case in 1998 and he through it was “probably a stretch too far…certainly in Australia, for it to happen anytime soon.

However, the issue of data and information sharing and comparative data was a live concern.” The Chappel v Hart case indicated that, where a patient asked about a surgeon’s experience in a particular procedure as part of the consent process, the surgeon may have a duty to inform the patient of their experience, but that the decision did not extend to a general duty to provide performance data. However the RACS spokesperson said if any surgeon was asked about their performance data, there was an onus on them to provide the information as “clearly, fairly and transparently” as possible.

The spokesperson added that performance data needed to be risk-adjusted for the complexity and difficulty of procedures.

Thumbs up for drug monitoring

Pain in the hip pocket

Still with the Feds, the Australian Government has committed $16 million to roll-out national real-time prescription monitoring of controlled drugs. The system will provide an instant alert to doctors and pharmacists if patients received multiple supplies of prescription-only medicines. The RACGP threw its support behind the move. President Dr Bastian Seidel said new data showed accidental overdoses of prescription opioids were greater now than from heroin overdoses. The Tasmanian GP said prescription monitoring was standard in his state and it was a vital tool for every GP and pharmacist to identify and help vulnerable people. He also urged pharmacists to back moves to restrict codeine sales saying “the consumption of these medications is currently running out of control with over 16 million items being sold over the counter in pharmacies every year.”

August was a month of out-of-pocket scrutiny following data released by RACS and Medibank Private regarding variations in surgery costs. Urology came under particular scrutiny with the CEO of Cancer Council Australia, Prof Sanchia Aranda, saying "out-of-pocket costs for these procedures show unwarranted levels of variation across Australia and at times are likely to cause significant financial hardship for patients unaware of alternatives to paying these high fees… It was reported in the RACS/ Medibank report that the average cost of a radical prostatectomy ranged from $14,553 to $55,928 depending on the surgeon. In WA 73% of patients were out-of-pocket for this procedure. The highest percentage was in the ACT with 100% of patients followed by 88% in NSW. Only 35% of patients in Victoria had out-of-pocket costs. Prof Aranda said the situation is even more concerning when aligned with evidence suggesting expensive robotic surgery offered little benefit to patients. The Cancer Council wants an improved standard of financial consent that ensures surgeons and other clinicians disclose all of the out-of-pocket costs associated with a planned treatment, along with treatment alternatives that may carry lower or no out-of-pocket costs. This

TGA ups the mesh ante

A performance-data future There is sure to be a lot more conversations such as Dr Rebekah McWhirter’s article and podcast on MJA Perspective last month regarding the release of performance data.

Her thesis was that increased health care data collection and broader expectations of transparency might lead to a legal duty to disclose performance data as part of

Bethesda Remembers Bethesda Health Care’s annual Remembrance Foundation Day celebrations acknowledged the opening of the hospital in 1944 and recognised the current staff who had been with the hospital on the journey.

Nurse Christine Hurley, who has been with Bethesda for 25 years, firstly with the Cottage Hospice and now in the surgical ward, was awarded the Matron Beryl Hill Exemplary Professional Practice Award, presented by Health Minister Roger Cook. Christine is pictured here, second left, with Mr Cook, Hospital CEO Ms Yasmin Naglazas and Executive Manager Clinical and Support Services Ms Deborah Bell.

10 | SEPTEMBER 2017

MEDICAL FORUM

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Medical Forum has been looking into the issue of perinatal anxiety (see August edition and P36) and next month it will be the subject of two days of workshops and social events put on by both government and non-government organisations. The Gidget Foundation Australia, Fiona Stanley Hospital, King Edward Memorial Hospital and the Big Pram Walk are putting on a symposium, dinner and workshop on October 6 and 7 for health professionals and the public.

According to Gidget data, nearly one in five mothers and one in 10 fathers are said to experience perinatal anxiety and depression and 50% of all parents experience adjustment disorders. On Friday October 6, FSH will host a one-day symposium with Dr Nicole Highet, Centre of Perinatal Excellence (COPE), launching the National Perinatal Mental Health Guidelines in WA. She is joined by Prof Vera Morgan, Prof John Newnham, Prof Rhonda Marriot and Prof Andrew Whitehouse. Dinner will be held that evening at Fraser’s. The following morning there will be workshops for GPs, allied health and consumers at KEMH with Prof Megan Galbally, Dr Sarah Moore, Dr Richelle Douglas, Dr Leanne Priestly, Kirstin Bouse, Dr Sue Jackson, Dr Leon Levitt doing the honours.

$64,000 a year for tuition and international students, who are expected to make up a third of the cohort, will pay $70,000. It will take the number of medical schools in NSW to eight and many professional and students groups say that is way too many. Macquarie medical students will also be required to spend five months of their clinical training in India.

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Smooth as silk Just a few days ago, the Subiaco-based Ear Science Institute of Australia took receipt of the first tranche of its $4m grant from the Wellcome Trust in the UK to run human clinical trials for its ClearDrum device which is expected to help those suffering from chronic middle ear disease caused by ruptured ear drums. ESIA’s Prof Marcus Atlas and Prof Xungai Wang, from Deakin University, have been working on the project for nearly a decade. ESIA CEO Sandra Bellekom told Medical Forum that human clinical trials

issue and more will no doubt be thrashed out in the final report of the Senate Committee inquiry into the value and affordability of private health insurance due to be released on November 27.

Website kicks goals The painHEALTH website developed by a consortium including people from WA Health,

would start mid-2018 in WA and several other states. Middle ear disease affects millions all over the world and having a solution to multiple painful and often unsuccessful surgical interventions for so many people was an obvious attraction to the charitable Trust, which requires projects to focus on social need. Sandra said this clinical imperative has always been a driving motivation at ESIA. “From a clinical point of view there is a deep level of frustration, not just among ear surgeons but audiologists everywhere, to see the same patient return over and over again for sometimes up to 5-6 grafts until they give up. Alleviating this patient suffering has been the real drive.”

The device is similar in appearance and size to a contact lens and is created by a bio-compatible silk implant on which the patient’s own cells grow to repair the eardrum. Travelling alongside clinical trials is its commercialisation, which Sandra says is also a priority. “We have to ensure these devices get out and into patients and for surgeons to use sooner than later and for it not just to be a journal article but be something meaningful.”

Curtin University and UWA and led by A/Prof Helen Slater and pain medicine physician, Dr Stephanie Davies, announced during Pain Week that it had recorded more than 8.1m hits since its launch in 2013. It has had about 620,000 visitors from more than 150 countries averaging about 410 visitors a day.

The website now has improved interface for use on smart devices.

BY THE NUMBERS: Burden of Respiratory Diseases

70.3%

• The Chair the Child and Adolescent Health Service Ms Debbie Karasinski has resigned as chief executive of Senses Australia after 16 years.

• A/Prof Erin Godecke, Senior Research Fellow at Edith Cowan University and a speech pathologist who works in acute stroke care and rehabilitation has been appointed to the Stroke Foundation’s Clinical Council.

• Dr Nicole Smith, from UWA’s School of Molecular Sciences, was awarded $720,144 to study four-stranded DNA as a treatment for Alzheimer’s and frontotemporal dementia (FTD).

• Dr Glen Power resigned as CEO of St John of God Midland Public Hospital and Medical Director Dr Allan Pelkowitz resigned a few days later. Mr John Fogarty, SJGHC’s Executive Director of WA Hospitals, is acting CEO while the group recruits replacements.

• Prof Valérie Verhasselt has been appointed the Larsson-Rosenquist Chair in Human Lactology – the first in the world – in UWA’s School of Molecular Sciences.

The Swiss-based Larsson-Rosenquist Foundation’s decision to support UWA is in recognition of the pioneering work of E/Prof Peter Hartmann in the area of human lactation.

• Ms Emma Buitendag is the new CEO of Epilepsy WA. She was previously at Alzheimer’s Australia WA.

The percentage of the overall respiratory disease burden in 2011 that was non-fatal

• Mr Simon Walsh, formerly Western Power executive manager of customer and corporate services, is HBF’s new general manager of strategy and ventures.

(There has been a 7% reduction in the overall burden from respiratory conditions between 2003 and 2011, Years of Life Lost (YLL) has decreased 13%; Years Lived with Disability (YLD) has decreased 4%)

• A/Prof Christopher Etherton-Beer (below) from UWA’s School of Medicine and his team were awarded an NHMRC grant of $586,000 to determine the extent that improved medication management produced better health and functional outcomes for people living with dementia.

• 92.3% of interstitial lung disease burden was fatal •

• Surgical Oncologist Prof Christobel Saunders is the joint winner of the WA Scientist of the Year for her clinical and research work especially into breast cancer. She shares the award with biologist Prof Harvey Millar. Paediatric infectious diseases specialist Dr Asha Bowen from the Telethon Kids Institute was named Early Career Scientist of the Year for her work reducing skin infections (particularly impetigo) in Aboriginal children.

91.8 of pneumoconiosis burden was fatal (Recent reports of Coal Workers’ Pneumoconiosis in Australia cite six confirmed cases in the Queensland coal industry between May 2015 and February 2016 (MJA).)

• 47% of COPD burden was fatal • 6.8% of Asthma burden was fatal • COPD constituted 42.8% of the respiration conditions burden; Asthma was 28.6% • Women experienced a higher percentage of the burden (YLD) – Asthma 54%; COPD 55%; upper respiratory 52%

• Tobacco use is an attributable risk factor in 36.2% of all respiratory conditions (Source: The Burden of Chronic Respiratory Conditions in Australia 2011, AIHW)

MEDICAL FORUM

SEPTEMBER 2017 | 11

spotlight

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Life After the Siren Western Force star Matt Hodgson has hung up his boots after 139 Super Rugby games and 11 caps for Wallabies with some big scores to make off the field.

Playing for the Wallabies and captaining Western Force means putting your body on the line every time you run onto the field. Matt Hodgson, who hung up his rugby boots last month, spoke to Medical Forum about the collateral damage of elite sport, juggling the often-tricky transition to retirement and the problematic future of the club itself.

“I don’t think it’ll be the referee’s final whistle when it hits home that it’s all over. It’ll be when the boys go back into pre-season training next year. Probably even more so when I turn up at the first game and have to sit in the stands. I’ll certainly be feeling it then!”

“And as for physical problems after a pretty torrid career, it’s already a bit tricky on cold winter mornings. I’m actually booked in for 10 surgical procedures at the end of the season and they’ll do a full body scan as well. It’s important to document them now because we have a three-year contractual agreement with Australian Rugby that ensures that any physical issues will be addressed.”

“We all put things off while we’re playing, so I’m looking forward to getting my body back into good shape. I certainly don’t want to wake up in five years time and not be able to play with my kids.”

Back to the gym That is probably unlikely because Matt’s second career is in the gym and fitness sector. He and his wife now own three gyms, with the latest one recently opening in Subiaco.

“We’re pretty excited about this next stage in our lives, and it’s wonderful that we’re going into business together. Physical fitness is a strong sector and we’re focusing on a niche area where people are time-poor and need guidance to structure their exercise program.”

“It also links in nicely with my commitment to

12 | SEPTEMBER 2017

improving mental health in our community.”

I’m talking with family and friends.”

The rugby world was rocked earlier this year when Dan Vickerman, long-serving Wallaby and teammate of Matt’s, committed suicide at the age of 37.

“Every game I’ve ever played has had its highs and lows.”

“Dan’s tragic death was a shock to all of us.

There had been signs that he was struggling with depression and he’d actually spoken to some friends about the problems he was having. Nonetheless, I had lunch with him not long before he died and I didn’t see any obvious signs of what was to come.”

“Sadly, most people are good at concealing just how much they’re suffering.”

Speaking up about depression “My own father struggled with depression after having a stroke, so this issue is close to my heart. I’m involved with the nonprofit charity LIVIN, which aims to remove the stigma associated with mental illness and raise awareness regarding suicide prevention.”

Make rugby entertaining “The code itself is going through an interesting stage. At the elite level it’s highly competitive but we also have to remember that a game of rugby, particularly at international level, is also supposed to be entertaining. And it’s that very aspect that allows us to market ourselves as professional athletes.”

“I play in the front row of the scrum, and I’m all for seeing more running rugby and fewer endless resetting of two huge packs of brawny footballers often resulting in a time-consuming penalty kick.”

“We definitely need to think about ways to increase crowd numbers and perhaps, as they do in the AFL, trial some rule changes in the pre-season.”

“The core of the LIVIN message is, ‘It Ain’t Weak to Speak’.”

Matt is leaving rugby behind at an uncertain time at the local level. One team will be axed from the Super Rugby franchise in 2018, and the ARU have nominated Western Force.

“These issues have certainly brought home to me the importance of a strong and loving family. If I hadn’t had that support, I think I’d have stepped away from rugby a lot earlier because it just makes it so much easier to share things and talk about life’s problems.”

“All this uncertainty has been frustrating.

One day you think you’re safe and the next it doesn’t look so promising. We’ve been living in limbo this season and there have been times when the club’s survival has distracted our onfield performance.”

“And once you have children the focus falls very much on them, which is a good thing.”

“It’s one of the hardest things to know when the time is right to step away from a professional sporting career. I slowly phased out of the captaincy this year and that was made a lot easier because of our wonderful playing group.”

Matt speaks about some of the high-points in a long career, and has a few interesting things to say regarding the game of rugby more broadly.

“I’ll always cherish the memory of running out for my first Force game to a sea of blue in the crowd, and captaining the Wallabies against the Barbarians was a big thrill. I guess a lot more memories will come flooding back when

“I’m very lucky, a wonderful family, a great football career and an exciting future ahead.”

By Peter McClelland

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SEPTEMBER 2017 | 13

close-up

Bringer of Mesothelioma Hope Some suggest that the stigma of smoking may affect the general view of the disease. The most recent AIHW report on the burden of disease may not help change that view. It found that 22% of the total cancer burden could be attributed to tobacco use.

Stigma affects treatment Anna sees the effects of this stigma on some of her patients.

“People often feel quite ashamed, particularly if they have had a smoking past. Unfortunately, the links weren’t known when most of our current patients started smoking. We were all up against an extremely powerful group of companies who worked very hard to market their addictive products.”

“While there isn’t a stigma around mesothelioma, there is no cure and with the number of survivors of lung cancer being relatively low, we don’t have large groups of people with lived experience of surviving these cancers to actively campaign for funding and awareness.”

Anna said the numbers of West Australians diagnosed with mesothelioma had plateaued but even so there were more than 100 people a year diagnosed in WA.

Prof Anna Nowak on a recent family holiday at Uluru.

With mesothelioma rates in WA rivalling those anywhere in the world, it’s little wonder that some of the best science to treat it, with a long-term view to curing it, is happening here at Sir Charles Gairdner Hospital.

One of the key leaders in the field is Prof Anna Nowak, who has devoted the past 18 years, first as an oncology registrar and now as a clinician/ researcher at the National Centre for Asbestos Related Diseases (NCARD), to helping mesothelioma patients.

When Medical Forum spoke to her, she was two patients away from completing a national clinical trial exploring the efficacy of a combination chemotherapy and immunotherapy treatment.

“We recruited 54 patients incredibly quickly and the trial will be completed in less than eight months and while we haven’t had a proper look at the results yet, we’re pretty excited. With all the preclinical work we’ve done in mice using different combinations of chemotherapy and immunotherapy, we are cautiously optimistic,” she said.

The use of older therapies, or as Anna describes them, one-sizefits all therapies, are able to be ‘personalised’ with the addition of immunotherapies.

Personal biomarkers “We are also looking at how to identify what’s in a person’s own cancer and how their immune system is reacting to it in order to turn that into a personalised cancer vaccine. That’s focusing more on people with lung cancer, rather than mesothelioma, but it is all work towards the common goal.”

Anna’s work was acknowledged in March by the International Mesothelioma Applied Research Foundation with the Pioneer Award, which she accepted at an international symposium in the US. Cancer Council WA recently released it's WA Cancer Registry report on cancer survival data. It revealed steady progress for all cancers but particularly for people with melanoma, breast and prostate cancer with survival rates exceeding 90%. The most common low-survival cancer is lung cancer followed by cancers of the pancreas, liver and brain.

It is argued this data should be driving the direction of future research investment.

14 | SEPTEMBER 2017

“Asbestos exposure is still a risk and we need to be mindful of the many people who were exposed as children, or through DIY renovations.

Asbestos is being dealt with in our community on a daily basis by people who are removing it with varying levels of protection.”

“The public needs to remain vigilant.”

Anna’s interest began when her oncology supervisor and mentor Dr Michael Byrne put her onto a mesothelioma research project when she was a trainee.

“That led to a PhD in chemo-immunotherapy. It is serendipity that the project as a registrar became a career-long passion to find a cure,” she said.

Driving force of patients “The more you know about something in medicine the more rewarding it becomes and the patients are very motivated and very generous to participate in research. Everyone, deep down, hopes they will be the ones to benefit.”

“I have a different definition of success than, say, that of a surgeon.

Mine is to be able to stand beside a patient and their family and provide some measure of hope along the way for a better outcome, which will allow them to live a little longer and a little better.”

“Many of my patients express a preference for ‘quality over quantity’ when they are diagnosed with advanced cancer. Quality-of-life research in cancer is helping us to understand the balance between quality and quantity when choosing treatments, choosing to have treatment, or understanding what symptoms and needs are most important to address.”

“It comes as a surprise to people that effective treatments can improve quality of life by reducing symptoms and tumour volume.”

Resilience is important for everyone.

“Resilience sets you up to be there; that, and the knowledge you can’t best help your patient if you’re falling apart yourself. But you also have to be extremely resilient to be a researcher because you’re always bouncing back from failure – be it a grant application or a paper that doesn’t get accepted. You need courage.”

By Jan Hallam ED: See P21 for treating the mental health of cancer patients.

MEDICAL FORUM

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Prof Anna Nowak has devoted her working life to making the lives of mesothelioma patients longer … and better.

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SEPTEMBER 2017 | 15

Feature

Preventing Unnecessary Transfusions The WA Health Department has set about changing the way its staff makes decisions about blood transfusions and patients’ lives have improved.

For centuries the medical profession has be mesmerised by blood – particularly besotted with taking it out and putting it back in. What period drama would be complete without a fevered hero being ‘cupped’ or a hospital soapie not awash with doctors in theatre screaming for more blood?

“Blood transfusion is a form of liquid organ transplant, which brings both short-term and long-term risks. In the short term, we could be looking at things including fever, allergic reactions, fluid overload, toxicity from components of the blood which has been treated to facilitate storage, and infections,” Michael said.

In real-time and real-life, the WA Patient Blood Management (PBM) Program is changing those scenarios not just here in WA but nationally and internationally.

“However the long-term risks have not always been so obvious, and are thought to be related to immune reactions triggered by allogenic blood, even with careful cross-matching.”

Haematologist Prof Michael Leahy is the lead author of the paper, Improved outcomes and reduced costs associated with a health-systemProf Michael Leahy wide patient blood management program, which was published recently and is receiving significant international attention.

The retrospective observational study examined the health and economic outcomes of a six-year study of 605,046 patients admitted to four major adult tertiary-care hospitals between July 2008 and June 2014.

The study’s outcome measures included red blood cell (RBC), fresh-frozen plasma (FFP), and platelet units transfused; single-unit RBC transfusions; pre-transfusion haemoglobin levels; elective surgery patients anaemic at admission; product and activity-based costs of transfusion; in-hospital mortality; length of stay; 28-day all-cause emergency readmissions; and hospital-acquired complications.

Negatives of transfusions Many studies had shown adverse outcomes from blood transfusions in various clinical situations, including increased infections, increased hospital length of stay, immunosuppression and increased mortality.

“There is also a dose-related effect (that is the more units of blood transfused, the greater the risk) which can be measured more than 10 years after transfusion.”

PBM had its origins at the privately run Kaleeya Hospital in East Fremantle.

Interest in ‘bloodless surgery’ Clinicians had a growing interest in exploring the mounting overseas evidence around ‘bloodless surgery’ in part because some of the hospital’s patients belonged to the Jehovah’s Witness faith and refused blood transfusions on religious grounds.

Many patients admitted for elective orthopaedic surgery were found to be anaemic and requiring iron replacements. Moving to pre-operative assessment to identify and manage all anaemic patients by increasing their iron levels before surgery was seen as a logical evolution.

Michael, who was at Fremantle Hospital at the time, said some of those ideas flowed to the public system from those surgeons at Kaleeya, who had public lists at Fremantle.

With increasing local and overseas evidence showing the benefits of PBM, in 2008, WA Department of Health initiated a six-year project across four tertiary sites to implement the program with a larger population in multiple clinical settings.

“With the State’s increasing population and falling blood donor pool it was becoming

clear that the usage rate of blood by the hospitals was going to outweigh the donation rate,” “It just adds another dimension to the fact that we needed to change our practice,” Michael said.

Improvements being made The study period showed major improvements in patient outcomes including: • 28% reduction in hospital mortality • 15% reduction in average hospital length of stay • 21% decrease in hospital-acquired infections • 31% decrease in the incidence of heart attack or stroke.

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WESTERN AUSTRALIA

Feature

PATIENT BLOOD MANAGEMENT PROGRAM The Western Australian Patient Blood Management Program recently published the world’s largest study on patient blood management outcomes. The study included over 600,000 patients admitted to Western Australia’s four major adult hospitals between July 2008 and June 2014. Over the six-year study period, the program was associated with:

IMPROVED PATIENT OUTCOMES AMI/stroke length of stay infection

mortality DECREASED

DECREASED

DECREASED

28%

21%

DECREASED

15%

31%

IMPROVED KEY PROGRAM INDICATORS

single unit

pre-transfusion

pre-operative

anaemia

haemoglobin

transfusions

DECREASED FROM

DECREASED FROM

INCREASED FROM

14%

73g/L

64%

21%

79g/L

33%

TO

TO

41

decrease in

red blood cells

plasma

47

%

27

%

Other jurisdictions and hospitals have focused on single speciality aspects of PBM such as in surgery or critical care. The WA study showed how to implement PBM across all aspects of hospital care, in both surgical and medical specialities.

“The WA program was unique in that it placed trained PBM clinical staff in key positions in each hospital so they could provide leadership, feedback and education to other medical staff on the use of blood conservation and the judicious use of blood products,” Michael said.

TO

REDUCTIONS IN UNITS OF BLOOD TRANSFUSED

decrease in

“We also use a number of different strategies in the operating theatre to help minimise bleeding, including new technologies and pharmaceutical agents (such as TEMs, cell savers and tranexamic acid) to help conserve a patient’s own blood. PBM is about educating clinicians and patients about blood conservation as well as thinking about the potential benefits and risks of a transfusion.”

%

decrease in

platelets

The study period also showed a 41% reduction in the use of RBC, FFP

ACTIVITY BASED COST SAVINGS PRODUCT COST SAVINGS andOver platelet products, direct savings of $18.5 million.

PRODUCT COST SAVINGS ACTIVITY BASED COST SAVINGS the six-year study period bloodresulting in ...however with cost the hospital costs of administering a transfusion added,

When health systems produce figures like that, other health systems sit up and take notice. Recently, the European Commission’s Director-General of Health and Food Safety announced it was adopting WA’s PBM model as a standard of care.

Closer to home, the Australian Commission on Safety and Quality in Health Care has now included PBM as a national priority. Such is the acceptance of PBM in hospitals, that the UWA Professor of Surgery, Dr Jeffrey Hamdorf, is now introducing it in the medical school curriculum.

coststudy savings were: savingscosts are estimated to be between: Over theproduct six-year period withthe the hospital of administering a transfusion added, Overall savings, which include...however the cost ofgross processing blood donations blood product cost savings were: the gross savings are estimated to be between: by the Australian Red Cross Blood Service along with administering transfusions in hospital, is estimated to be between $80-100 million. .

“The next step for us is to have PBM at the primary care level. We are working with GPs to see that blood screening is identified and managed before the patient comes to hospital. Those efforts are continuing in a number of Perth clinics and yielding good results,” Michael said.

changing the culture around blood transfusion, making the focus around

Elements of the program are now used in all of the State’s public hospitals and many of the private hospitals are also on board, embedding PBM as a standard model of care.

AND

$“An18.5M $is1 0 0 18 5 $M80M– 8I0 100M important its focus M I L -on I LofLthe Oprogram N M I L L Ifeature O Nof the success For more Leahy MF etoutcomes al. Improved reduced costs with associated For more information see:information Leahy MF see: et al.

Improved andoutcomes reducedand costs associated a healthon system-wide individual patient need, rather than a transfusion exercise based with a healthPatient system-wide Blood Management Program. Transfusion.

Blood Patient Management Program. Transfusion.

haemoglobin levels,” Michael said

better health * better care * better value

“Patients with anaemia need to have the cause established rather than just receive treatment with a blood transfusion. If the patient is stable and not bleeding, there really is no point in giving blood if they are not symptomatic.”

It looks like the TV scriptwriters will need to change their tune.

For further reading: www.medicalhub.com.au/wa-news/featurearticles/4317-patient-blood-management

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guest column

NDIS: Complexity and Uncertainty The National Disability Insurance Scheme (NDIS) is an incredibly complex social policy. At an estimated cost of $22b and potentially impacting the lives of 450,000 Australians – not to mention their families – the NDIS is one of the most significant initiatives devised in Australia. However, in WA, the complexity of implementation is increased as uncertainty regarding the model remains.

The NDIS model has at its core the idea that people living with disability should have choice and control over the services they access and how they access them. Like the NDIS itself, this is an almost universally agreed aspiration.

Many aspects of the NDIS which are designed to achieve this outcome were inspired by WA’s pre-NDIS disability services model.

Elements such local coordinators (assisting people to access services and navigate the processes) and individualised funding and person-centred care (supporting choice and control) were part of the original WA model.

As a result, the previous state government did not agree to hand over disability services to the NDIS in the way that the other states and territories did.

WA’s arrangements are unique in that decisionmaking control and leadership are retained here. This has great advantages...

Rather, while each state and territory bilateral agreement with the Commonwealth is different at the margins, WA’s arrangements are unique in that decision-making control and leadership are retained here. This has great advantages, not least of which that the now redundant Disability Services Commission was able to continue its close relationship with the disability services sector and pass that relationship onto the new Department of Communities, created by the new McGowan Government.

However, the State Government also opened up a can of worms when it questioned whether the unique WA arrangement should be retained or whether WA should join other jurisdictions and hand over control to the NDIS.

It is a very difficult question – there are marginally more costs borne by the WA Government under the current arrangement but, on the other hand, disability service providers have a strong relationship with the state government (which is not replicated by an NDIS that does not see a relationship with the sector to be important) and the NDIS is still very immature.

These two factors ensure that uncertainty reigns under the NDIS for service users and providers alike – prices are not settled satisfactorily, peripheral services, such as transport, remain unresolved and demand remains unconfirmed. The level of uncertainty is also compounded by the fact that the NDIS has a new board and will have a new CEO soon, which could potentially change the game.

It is clear that a WA-based model articulating into the NDIS is likely to be a sensible and risk-averse model to adopt at least in the short-to-medium term as the NDIS beds down and the realities of costs, pricing, service delivery requirements and demand become better known.

C L I N I C A L R E S E A R C H S T U DY F O R

SOCIAL ANXIETY DISORDER We are recruiting for a Phase 2a study to investigate the safety, efficacy and tolerability of a new investigational medication as a possible treatment for social anxiety disorder. Participants must meet the following minimum criteria: • Male and female participants, 18-64 years of age with moderate to severe symptoms. (will be assessed for eligibility using the Liebowitz Social Anxiety Scale).

• Female participants must not be pregnant, breastfeeding or able to become pregnant.

• Participants must not currently be using psychotropic medications or in psychotherapy for social anxiety disorder.

• Participants will receive a placebo or the investigational oral medication during the study.

Maximum participation time in the study will be 20 weeks and participants will remain under your care and returned to you after the study ends.

For further information please contact: Nicole Emmott on 08 9347 6574 or nicole.emmott@health.wa.gov.au Approval to conduct this research has been provided by the Human Research Ethics Committees of the North Metropolitan Mental Health Service Research Ethics and Governance Office (NMHS MH REGO).

Any person who wishes to raise an ethics issue or concern about this research project may contact the NMHS MH REGO Executive Officer on (08) 9347 6502 or NMAHSMHREGO@health.wa.gov.au

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MEDICAL FORUM

back to CONTENTs

UWA’s Prof David Gilchrist sees benefits in WA sticking to its own form of the NDIS but uncertainties around prices and likely demand.

GUEST COLUMN

Melanoma Service Lives to Fight On back to CONTENTs

The future of the WA Melanoma Advisory Service hung in the balance until lobbying saw the decision reversed. WAMAS director Dr Mark Hanikeri explains.

The Western Australian melanoma advisory service (WAMAS) was established in 2000 at St John of God Hospital in Subiaco and has been jointly funded by the Department of Health (DoH).

Its aim is to provide multidisciplinary advice for melanoma patients with advanced disease without the need for interstate travel.

WAMAS is populated by specialists from all aspects of melanoma treatment including surgeons, dermatologists, oncologists, pathologists and radiologists. They provide their time and services, essentially probono. WAMAS has also collaborated with organisations such as the Cancer Council WA through the WA Clinical Oncology Group, the Melanoma Institute of Australia (MIA) and MelanomaWA, to provide accurate and contemporary advice and education opportunities for patients and clinicians.

Since 2008, there have been plans to transition WAMAS into a treatment and advisory service, modelled on MIA, and relocating the service to the Perkins Institute.

This prompted the DoH to review funding for the service. Based on this review, the DOH

informed WAMAS that it would no longer fund a state-wide melanoma-specific advisory service.

The proposed alternative was a public hospital multidisciplinary team based at Sir Charles Gairdner Hospital to assess general skin cancer patients, modelled on a similar clinic at Fiona Stanley Hospital. There were no plans to provide a service for patients with melanoma in the private setting, in rural areas or in the eastern metropolitan area.

The DoH decision was met with objections from WAMAS, MelanomaWA and the Cancer Council. Thankfully, following a meeting last month with the Director-General for Health, Dr David Russell-Weisz, that earlier decision was reversed pending further negotiations.

Over the past decade profound advances in melanoma management have been made.

Surgical procedures including sentinel node biopsy together with access to PET-CT have led to improvements in staging, while new adjuvant medications including BRAF inhibitors and immune modulators have improved the prognosis of patients with advanced disease.

These modalities rely on clinical research to demonstrate their efficacy and benefit to patients and the community. The pace of treatment advances has made it difficult for clinicians to keep up with optimum care for these patients. WAMAS has facilitated standardisation of management opportunities for patients referred to the service, regardless of insurance status or postcode, including diagnosis confirmation, appropriate surgical and medical care and access to clinical trials.

Currently, melanoma management recommendations are being standardised across Australia. These prescribe that patients who have a primary melanoma with a Breslow thickness over 1mm or metastatic disease are referred to a multidisciplinary team. This has now become the standard of care for these patients.

The new, centralised, state-wide melanoma service based at the Perkins Institute is yet to be named but will be launched later this year and will commence activities from January 1, 2018.

ED: A GP education event will be held on November 22 See http://wamas.org.au/upcoming-events.html

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MEDICAL FORUM

SEPTEMBER 2017 | 19

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feature

Conquering Cancer Fears Anxiety about cancer recurrence is seriously affecting nearly half those who have cancer treatment and new approaches to deal with it are needed. commitment therapy, which, when I first heard about it, I thought sounded like ‘just suck it up’ but, in fact, it is good common sense.”

Prof Jane Turner is a Queensland psychiatrist who has been working in the area of psycho-oncology for more than 25 years. She’s had a lot of difficult conversations with cancer patients about their fear of the disease recurring and she’s also found some constructive ways to make those conversations meaningful and effective.

Jane, who will be in Perth speaking with GPs later in September for St John of God Subiaco Hospital’s Health and Medical Research Week, said the issue of cancer recurrence is an area gaining more traction and attention in clinical and research circles.

“About 40% of people after cancer treatment have a debilitating fear that it will come back and this is not just people who have early cancer treated. Even people with metastatic cancer worry that it will progress further,” she said.

Prof Jane Turner

world view. If you’re nine and your mother dies of breast cancer and you get breast cancer, it doesn’t matter if people tell you that you have a great prognosis, you will still worry that you will die.”

Cancer and bad luck

“We don’t exactly know why some people have this problem more than others but what is important is that it doesn’t seem to go away on its own.”

“The other aspect is information and misinterpretation. If there was a delay in diagnosis or there were complications, you can understand why that person might think the cancer will come back, ‘because I’m so unlucky with everything else’.”

Anxiety post-cancer treatment, and its ‘successfulness’, is a natural response for patients and their families alike but treating it needs a different clinical approach.

“By helping people understand their past experiences of loss and grief, they are able to see the logic of their feelings and that is liberating for them.”

Cancer fear is rational

The next step is for people to embrace living rather than just surviving.

“CBT is a widely accepted treatment for anxiety and it is very helpful if people’s feelings and fears are irrational but it doesn’t work so well with cancer patients. Even if a patient is cancer free it can recur, that’s a reality. We have some of the best cancer survival rates in the world but no one can guarantee, so, to some extent, the fear of recurrence is rational.”

However, this anxiety can lead to a lower quality of life.

“These patients often get stuck in their anxiety. They may drink too much or become sedentary and when you ask them about these lifestyle things, they say, ‘what’s the point, the cancer will come back’. You find them withdrawing from relationships.”

“We have just completed a study which paid a lot of attention to this. It drew on the third wave of therapies – medi-cognitive therapies – acknowledging that the thoughts are not the problem, they are in fact reasonable, but there needs to be new ways of dealing with them.”

“An intervention called Conquer Fear has been developed that consists of five faceto-face sessions. The first step is to help the person understand why they have come to this point.”

“We don’t have data to back this up, but I have been a psychiatrist in this area for 25 years and there are events that shape your MEDICAL FORUM

“In the sessions we talk about values and goals. ‘OK, I’ve survived this, but what do I want for myself.’ The program uses components from acceptance and

“It gives people the chance to decide: ‘what can I change about this situation?’. Rather than squander resources endlessly, a person can choose to disengage. I use a car analogy.

Cancer is an unwanted passenger in the backseat. I can focus on that unwanted passenger and risk an accident or I can keep an eye on it in the rear-view mirror but keep on driving.”

These scenarios will be familiar to many GPs and Jane says GPs are often in the hot seat because they have at their fingertips the tools that can help patients’ anxieties bloom.

“People seek reassurance from GPs who may be pressured to do unnecessary tests.

If someone says they are worried, a good response is ‘Yes, you would be worried. How much is it interfering with your life?’ GPs can correct misconceptions and alleviate aggrieved behaviours.”

“GPs have a role in helping patients get to grips with their new normal and help them tolerate it. Cancer leaves scars, both physical and emotional, and they can both heal. However, if you scratch them hard enough, the scars will bleed. Anxiety is that scratching.”

“Being angry and upset are reasonable and rational thoughts. We just have to help those who can’t move beyond them.”

ED: See www.sjog.org.au/researchweek

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SEPTEMBER 2017 | 21

Feature

back to CONTENTs

See that dollar go further!

World Sight Day in Bali in October is expected to be busy but satisfying for all the volunteers of the John Fawcett Foundation.

One thing is for certain, donations can attract results overseas, particularly if you have someone on the ground making it happen. The John Fawcett Foundation (JFF) is unique in these ways and others: • John is a West Australian, with philanthropic wishes for his adopted home of Bali and the rest of the Indonesian archipelago. JFF would be stoked if you helped too.

• John ensures your donation doesn’t all go in administration – it was 12.5% last audit!

• World Sight Day (October 12) is being marked by the JFF with a special, sevenday event in impoverished Situbondo, East Java. Four mobile eye clinics, four ophthalmic surgeons (over 400 cataract blind people) and JFF’s full screening team (seeing an estimated 2500 people with eye problems, handing out about 1875 pairs of glasses and treating 1250 people with eye drops).

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MEDICAL FORUM

• You are invited to join a consortium of donors to raise the A$55,000 for the seven-day program. You are welcome to visit Situbondo and see firsthand the difference these incursions make to many people’s lives.

“Donors who have given significant amounts to specific activities are sent a report on those activities, complete with photographs.

We always welcome people visiting our Foundation’s base in Bali – going out with the mobile eye clinic on one of the screening/ operating programs is the best way to get a real feel for what we are doing and the significance of our assistance,” John said.

While A$95 restores sight to someone affected by cataracts, $2500 brings a twoday screening/operating bus to an outlying village in Bali where about 500 locals are screened, glasses and eye drops given to around 300 people, and 10 people receive sight-restoring operations. Satisfying results indeed!

Training of local people on-the-job has been part of the Foundation’s modus operandi, whether training ophthalmologists or nurses.

A close relationship has blossomed between JFF and the Centre for Ophthalmology and Visual Science UWA, The Lions Eye Institute and the Perth Eye Hospital.

All JFF’s services are for the poor and are free for the patients. Since the project began in 1991, about 48,000 people have received sight-restoring operations, and nearly one million people have been screened for eye problems.

In Indonesia, some three million people are needlessly blind from cataracts, causing a huge drain on the economy, not to mention personal distress.

There are cultural barriers to overcome.

Family elders must give permission. Hindu beliefs often attribute today’s physical illnesses to superstition or an act in a previous life. The elderly do not step forward because they feel less important and are more accepting of their lot. So, gentle campaigning is part of the philanthropic work.

“I would like to ask WA doctors to assist JFF financially – in whatever way they can.

Funding is a huge issue for the continuation of our work. JFF is tax-deductible in Australia and JFF is a WA-based organisation.”

By Dr Rob McEvoy See www.johnfawcett.org to donate

Dr Scott Phung

Q&A

St John of God Murdoch Hospital opened the Murdoch Sleep Centre. Why? This establishes a comprehensive sleep service south of the river. Sleep disorders are very common but if untreated can have a significant impact on health and well-being.

The Murdoch Sleep Centre, a collaboration between St John of God Murdoch Hospital and Sleep Studies Australia, addresses the need south of the river for a convenient and efficient diagnostic and treatment service with local clinical support.

What are some of the specialist services provided?

The inpatient sleep laboratory is equipped with the latest in sleep diagnostic equipment. Sleep disorders seen include sleep apnoea to more complex hypoventilation syndromes, insomnia to parasmonias. A wide range of treatment options are supervised by experienced sleep technicians through Sleep Studies Australia. Clinical support is provided with both inpatients and outpatients. Referring doctors can also talk to the sleep physician who has reported the sleep study.

What has the feedback been?

It has been tremendous so far. Patients ask if they can have a sleep study at Murdoch.

Previously the answer would have been no. Patients have also been positive about the overall experience during the night, particularly the professionalism of the staff.

How serious and widespread are sleep disorders?

Sleep disorders are common but under-recognised, affecting more than 1.5 million Australians (8.9% of the population)1. Up to 80% of people with a sleep disorder are undiagnosed. Sleep disorders are a personal and public health burden. They are associated with serious health consequences including depression, diabetes, cardiovascular related disease and reduced life expectancy. They can contribute to motor vehicle and workplace accidents. The economic costs include lost productivity and increased use of health care.

What most commonly presents and what about treatment?

Obstructive sleep apnoea is the most common presentation to a sleep centre.

Treatment success is quite high due to improvements in technology for both CPAP and Mandibular advancement splints as well as the role of surgery in selected patients.

Why did you choose to specialise in Sleep Medicine?

Initially my exposure was the more acute side with the use of non-invasive ventilation in respiratory failure. Now, it is more outpatient management of sleep disorders. What is satisfying is the life-changing difference you can make. There is often a very large and quick response to effective treatment.

Any new innovations in Sleep Medicine?

Most exciting is the customisation of CPAP masks. 3D scanning of the face and head enables masks to be tailor-made with 3D printers overcoming the common problems of current masks.

References: Re-awakening Australia. Sleep Health Foundation. Deloitte Health Economics (2011).

• Home-based sleep studies via partnership with WDP at selected collection centres including Belmont, Midland, Mt. Hawthorn, Myaree, Rockingham and Beldon; Albany opened August 2017; Kalgoorlie and Geraldton are well-established.

• Open access to full, attended sleep studies at: - St John of God Murdoch (private health insurance required).

- Palmyra Professional Centre (no private health insurance). This is the only service of its type in WA. • Supervised trials of nasal CPAP therapy using a variety of CPAP equipment manufacturers.

• Trials of alternative therapies including Body Position therapy and Provent (nasal sufflation).

• Consultations via Dr Scott Phung.

All sleep studies reported by accredited Sleep & Respiratory Physicians.

Quick turnaround time and no waiting list (booked in one week).

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skemp@sleepstudies.com.au www.sleepstudies.com.au Ph: 1300 65 1234

MEDICAL FORUM

SEPTEMBER 2017 | 23

Finance

Challenging Not-So-Super Advice With changing superannuation legislation, some doctors may be advised to rollover away from state fund. Lawyer David Huggins says, don’t!

David Huggins

Many doctors who have worked in the WA public health system will have been members of the West State super fund. West State is constitutionally protected, which means that it is taxed differently to other super funds.

A common scenario is that a doctor will work for some time in the public system then leave and become self-employed. These doctors could continue to be members of West State. For these doctors, West State offered an important tax benefit that allowed them to make personal concessional contributions up to an overall cap of $1.415m over their lifetime. These contributions were tax deductible.

A member of a standard super fund could only make a tax deductible contribution to a maximum of $35,000 a year. The tax benefit associated with being a member of West

State was therefore valuable and should only have been given up for a very good reason.

Sadly, there have been a number of instances where doctors have been advised by their financial planner to leave West State by rolling their super to another fund. Doctors who have done this have potentially lost the benefit of hundreds of thousands of dollars of tax deductions.

The question arises, why was this advice given? There are three potential reasons.

The first is ignorance. West State was unusual and some financial planners who advised their clients to leave it were unaware that it was taxed differently.

The second is commissions. Financial planners may receive commission when clients switch to another super fund. This switch was often made in the context of re-arranging insurance where the insurance was linked to superannuation. Commission payments with respect to insurance were large. They operated as a powerful incentive for financial planners to advise their doctor clients to change funds to facilitate the rearrangement of their insurance.

The third is ownership. Many financial planners work for or are associated with companies that manage superannuation funds.

For some doctors who have moved, the result will be the loss of hundreds of thousands of dollars of taxation deductions. However, they do have extensive rights to recover their loss through an external dispute resolution scheme such as the Financial Ombudsman Service or through a court.

In the last Budget the Government announced it was going to set up the Australian Financial Complaints Authority, which will be able to award compensation with respect to financial planning complaints and unlike the court system complainants cannot have a costs order made against them.

It will replace the current external dispute resolution schemes and will for most complaints operate as an alternative to the Court system. The new body will make it easier to recover losses suffered as a result of poor financial advice.

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Practice Management

New Data Breach Legislation

By Mr Jerome Chiew www.critical-it.com.au The Federal Government passed Data Breach legislation in February this year. www.aph.gov.au/Parliamentary_Business/ Bills_Legislation/Bills_Search_Results/ Result?bId=r5747 The Notifiable Data Breaches Scheme (NDB) provides additional legislation to the privacy management framework, setting out the process that requires organisations covered by the Australian Privacy Act 1988 to notify individuals at risk of serious harm by a data breach.

Penalties, rectification and restitution can be levied against an organisation over a data breach event occurrence.

Not all data breaches are notifiable, the legislation only requires organisations to report breaches when it is determined that a data breach would most likely result in serious harm to individual(s) whom the information relates.

The Office of the Australian Information Commissioner (OAIC) opened comments, which ended August 2017, to engage the public in providing feedback for the draft legislation.

Shortly after the legislation was introduced to the House of Representatives in October 2016, the Australian Red Cross Blood Service (ARCBS) notified the OAIC about a serious data breach from their DonateBlood website. www.oaic.gov.au/media-and-speeches/ statements/australian-red-cross-bloodservice-data-breach After a lengthy 10-month investigation, it was found that a file containing personal information of over 500,000 individuals who had signed up on the website, was publicly available on the web server, managed by a third party provider. www.itnews.com.au/ news/blood-cross-escapes-penalties-indata-breach-investigation-470264 The ARCBS was ultimately not found to be directly responsible for the breach, although it did contribute to it. The majority of the blame was levelled at the website provider, Precedent, who failed to protect the sensitive information and also fell short of the privacy legislation on a number of fronts; inadequate safeguards were put in place to restrict access and no periodic auditing was performed.

promptly and appropriately in response to the data breach and subsequent investigation.

It is highly recommended that all organisations that come under the Privacy Act prepare for the NDB Scheme which is set to commence 22 February 2018.

The OAIC website has drafts of the scheme, which highlight who must comply, how to identify data breaches and other resources to help prepare for the start of the scheme.

Although the legislation is still in draft form at time of writing this, it is recommended doctors review the final scheme, assess and shore up any weak points in their organisation in relation to handling and storage of information, train staff to take appropriate steps to handle information in a secure manner, monitor and audit all information transactions and have a policy in place to deal with data breaches. See www.oaic.gov.au/ engage-with-us/consultations/notifiable-databreaches/

The OAIC did comment that both ARCBS and Precedent were very cooperative, acted

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SEPTEMBER 2017 | 25

ADVERTISING FEATURE

perth clinic the right service at the right time.

At Perth Clinic, one of our aims is to continuously improve the referral process for General Practitioners. We know that referring a patient can be time consuming and one of the roles of Perth Clinic’s Admissions Centre is to simplify the process as much as possible. We want to assist you so you can quickly refer to and access the full range of patient services that Perth Clinic has to offer, therefore ensuring your patients get the help they need, when they need it.

If your patient requires a psychiatric admission urgently and is willing to be admitted as a voluntary patient, contact the Admissions Manager on (08) 9488 2973 to discuss the referral. The referral should then be faxed to (08) 9481 4454 noting the request for inpatient admission.

The referral should include: • Patient details • Past history • Risk issues • Presenting problem/s • Physical problem/s • Drug or alcohol use; the severity of this problem may or may not exclude them

from admission.

The patient must have private health insurance that has no restrictions on psychiatric cover or alternatively have the ability to self - fund. Patients may find it helpful to contact their health fund provider if they are planning to access services.

Once the referral is received, the Admissions Centre will do the rest. The Centre’s staff are able to process referrals effectively and efficiently and with the assistance of electronic tracking, answer any queries quickly.

We will respond to you as soon as possible, but please be aware that not all patients will qualify and the more complex patients may take more time.

If there is a need for an urgent admission, for example a patient who is at risk of harm

26 | SEPTEMBER 2017

to themselves or to others, our Mental Health Clinical Nurse triaging the referral will speak directly with the Psychiatrist to decide the best way forward.

Patients who are suitable to be referred to Perth Clinic are voluntary patients; those who are willing to remain in the Clinic.

Referrals for involuntary patients, or those not willing to stay in the Clinic will not be accepted. Additionally, Perth Clinic does not accept referrals for patients under the care of a treating Private Psychiatrist who is not accredited to Perth Clinic.

If your patient requires an outpatient appointment, they can be referred through Perth Clinic’s First Available Appointment Service. Fax the referral requesting an outpatient appointment to (08) 9481 4454 and the Admissions Centre staff will assist in trying to get an early appointment with one of our Psychiatrists.

Perth Clinic recently welcomed Dr Navneet Johri, Dr Amir Tavasoli and Dr Monique O’Connor as new Consultant Psychiatrists to Perth Medical Suites and all are able to take urgent outpatient assessments in specialist fields of mental health.

Once a patient has been assessed by a Consultant Psychiatrist they can access all of Perth Clinic’s extensive therapy programs, specific to their needs.

Perth Clinic offers a seven day psychiatric service which includes: • Mood and Anxiety Disorder

Management and Therapy • Interpersonal Therapy • Alcohol and Drug Treatment and Therapy • Cognitive Behavioural Therapy • Dialectical Behavioural Therapy • Mindfulness Based Therapy • Electro Convulsive Therapy • Repetitive Trans Magnetic Stimulation Therapy • Adolescent Programs and Therapy • Relapse Prevention Support • Community Outreach Service Our therapeutic programs are evidence based, structured and delivered by experienced, skilled and trained mental health practitioners. Our aim is to provide patients with opportunity to build insights and develop skills to manage their mental health in an effective and empowering way.

All of these services can be accessed by day patients; admission as an inpatient is not a pre-requisite. In fact, for many of our programs, outcomes are greatly enhanced when patients complete them as day patients, where they can incorporate their newly learned skills directly and immediately into their home environment while simultaneously being supported by Therapy staff.

The case study opposite relates to recent referrals that highlight the referral and admission pathway, but also provides an example of our client centred treatment matching.

MEDICAL FORUM

CASE STUDY John is a 38- year -old male who was referred by his GP after crashing his car into a tree whilst intoxicated following an altercation with a colleague. After the accident, he attended Sir Charles Gardiner Hospital Emergency Department. He was discharged after being treated for his injuries and undergoing a Mental Health Assessment. Following his one night stay, John then went to see his General Practitioner.

John reported a decline in his mood over the previous two months following the death of his father six months before. He had been using alcohol excessively as a coping mechanism. Anger outbursts had been having a negative impact on his marriage and workplace relationships.

Over a period of three weeks John had been consuming 2 bottles of wine plus 6 beers every evening. He reported deliberately driving into a tree after threatening a colleague who accused him of not doing his job properly. John works as a lawyer and has been finding it increasingly difficult to fulfil his obligations to clients.

John does not have a diagnosis history and has not been involved with psychiatric services in the past. His paternal grandmother suffered with Depression and his paternal uncle had an alcohol addiction.

In the car accident, John fractured his right cheekbone. There were no other physical problems. The GP referred John, via telephone for an acute admission at 9.25hrs on a Tuesday morning. A referral letter and Health Fund Details were received at 9.40hrs.

John had top hospital cover. His referral was discussed with the Acute on-call Psychiatrist at 10.30hrs, who agreed to a crisis admission. After discussion with John, he was admitted to the Clinic at 12.30hrs.

John spent 12 days in the Clinic, detoxing and attending the Drug and Alcohol Therapy Program. Following discharge his Psychiatrist referred him to the Clinic’s Relapse Management and Prevention program and for individual therapy for grief counselling. He returned to work 5 weeks after crashing his car and is now managing to fulfil his obligations to clients with the support of his family, colleagues and the Clinic’s Day Patient Therapy Services.

If you would like further information or to discuss the referral of a patient to Perth Clinic, please fax a referral to (08) 9481 4454 or contact Kathryn Turner, Admissions Manager on (08) 9488 2973.

UPCOMING EVENTS Perth Clinic also hosts a series of dinner club events on a monthly basis which provides the opportunity for GP’s to attend presentations / education sessions delivered by Consultant Psychiatrists on a variety of specialist subjects giving an insight into treatments for various mental health diagnoses.

The Dinner Club invites you to enjoy dinner in a relaxed setting provided by our Executive Chefs whilst providing

the opportunity to view Perth Clinic’s environment, discuss available services, meet the clinical staff and ask questions about how to manage patients within your practice.

Psychiatrists on their particular specialist interests. The evening is informal with an opportunity for discussions and questions and to meet other members of the Perth Clinic Team.

The networking element assists in the development and maintenance of current and new relationships between Perth Clinic and GP’s and we have a series of events over the next few months all presented by Perth Clinic Accredited

The Dinner Club is held each month with a variety of subjects all delivered

by Consultant Psychiatrists that are accredited with Perth Clinic.

DATES

TOPIC

PRESENTER

6th September

Borderline Personality Disorder

Dr Ian Assumption

11th October

An Interactive Evening with Dr Nick De Felice

Dr Nick De Felice

Should you wish to attend these events or register your interest for any upcoming events, please do so by contacting Perth Clinic’s Corporate Services Secretary (Siobhan McElroy) on (08) 9488 2930 or email hospitalsecretary@perthclinic.com.au

Hospital Address: 29 Havelock Street, West Perth WA 6005 Phone: (08) 9481 4888 Website: www.perthclinic.com.au MEDICAL FORUM

SEPTEMBER 2017 | 27

guest column

Value Does Have a Price The Department of Health has released for public consultation six clinical committee reports from the Medical Benefits Schedule Review Taskforce – urgent afterhours primary among them, which as a GP Principal I am most interested in.

The focus of the urgent after hours report is aimed at preventing inappropriate use of urgent after-hours items. There is no attempt to change the descriptors for after-hours to enable appropriate after-hours attendance by the local GP. There is no attempt to strengthen the relationship of deputising services to the principal practice through either agreements or communication and medical records requirements.

We have the absurd situation in which my patients are not eligible for non-urgent after hours rebates until after 8pm, yet if I have already closed my door and return to the surgery, they can access these items from 6pm. Do I recall the nurse and receptionist for this? A deputising service with no prior relationship to a patient can access these rates after 6pm!

We do open until 6pm. We’ve decided it is important to cater for those who can’t attend

Does this mean gaming the system is already being practised with attendance items and chronic disease items? If so, this potentially disadvantages the very patients Health Care Homes is meant to support. in office hours. I’m pretty tired by then but I’d make it 8pm if it were worthwhile. The irony is that I will be spent when others commence their lucrative business.

The real money, of course, is in urgent afterhours calls. A lot of what I see during the day is urgent. Last week three of our doctors attended overdoses on two occasions: one brought to the surgery from the neighbouring pharmacy and one at the nearby bus stop.

Urgent can be anytime Both were resolved with teamwork in under an hour and so no Item 160, and it’s ‘draw

straws’ to be the doctor who receives the patient’s rebate. And don’t forget to beg the ambulance to replace consumables as no other fee can be raised for a bulk-billed attendance!

MBS reform for urgent attendances thus goes beyond descriptors of hours and urgency but also extends to issues of payment of several practitioners and nurses for team management of a patient, and co-payments for consumables.

I am also really interested in the report on MBS attendance items. I my opinion, Item 23 is the greatest evil at the heart of our primary health system. The ‘standard level B’ attendance is defined in part as a consultation lasting less than 20 minutes, i.e. no bottom line in time. The content descriptors are broad.

In contrast, ‘standard’ appointments are either 10 or 15 minutes. This makes sense: why spend more than 10 minutes on a problem when you need to double the time to receive an increased fee of less than double the amount? For a corporate player it would be irresponsible to shareholders not to minimise compliance with time and content.

Time is money After 22 years as a GP I can usually tell if someone is sick or not in a few minutes and confirm this with examination and prescribe, or not, and give a little advice in a few minutes more. To educate the patient how to manage themselves and avoid seeing me takes longer. To address prevention of the things that are most likely to kill or make them chronically unwell takes even more time. After 10 minutes, however, I am effectively losing money.

I support the RACGP position laid out in the paper, Working towards a sustainable healthcare system, (Version 1, February 2015), which proposed six time tiers for GP attendance Items (I would even have gone for six-minute intervals). Analysis of the College survey results found 73% respondents agreed with the proposed six time tiers and noted the lack of recognition of increased efficiency conferred by experience.

Our surgery has been shortlisted for the Health Care Homes Trials. We analysed 212 consecutive patients drawn from our appointment books. I compiled a list of 105 conditions I felt warranted the description of chronic conditions. About 80% (170) of our patients had two or more of these chronic conditions. The greatest number of chronic conditions listed for one patient was 22.

I suspect the Health Care Homes descriptors will be much more restrictive given their estimates (on a population basis) of about 20% of Australians having multiple complex and chronic conditions. The danger, of

28 | SEPTEMBER 2017

MEDICAL FORUM

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Bayswater GP Dr Rohan Gay, like many other GPs, is waiting and watching where the fickle finger of the MBS review will take primary care.

course, is that the incentive of the system appears to be to identify as much chronic disease as possible then to do as little about it as possible.

Gaming the system When visited by our local Primary Health Network representatives we did some backof-envelope calculations and determined that we could well be out of pocket with some of our more complex (Tier 3) patients. It was suggested that such ‘frequent fliers’ not be registered and treated on a fee-for-service basis!

This was alarming. Does this mean gaming the system is already being practised with attendance items and chronic disease items?

If so, this potentially disadvantages the very patients Health Care Homes is meant to support. Another possible way to game the system could be to exclude conditions necessitating high attendance (e.g. chronic pain, conditions requiring warfarin) from the registered conditions of participants. Yet another would be to refer patients to casualty once their ‘allowance’ is up.

The response from our local reps was, “but you wouldn’t do that, would you?” and in our case, they are right. Like many GPs, our loyalty is to our patients rather than any corporation or institution. As always, the main governor of our charges is ourselves.

Unlike any other branch of medicine, it is our enduring relationship with our patients, generally spanning years, often decades, and economic circumstances, which ultimately limits our impost on them and contributes to our declining remuneration made worse by the Medicare Freeze.

That’s in our case. I’m sure in other cases, cooler heads will rationalise the model to greatest financial advantage and patient care be damned.

CURRENT UPDATE OF ACCREDITED PSYCHIATRISTS AT PERTH CLINIC MEDICAL SUITES 33 Havelock Street Ph: 9488 2946 Fax: 9488 2954

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Dr Lawrence Blumberg

Dr Ian Assumption

Dr Julia Charkey-Papp

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Dr Raymond Wu

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Dr Johann Combrinck

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Dr Zlatan Golic

Dr Nick De Felice

Dr Mark Hall

Dr Pei-Yin Hsu

Dr Margaret Lumley

Dr Daniel Morkell

Dr Rebecca Rhys-Maitland

Dr Chun (Solomon) Ong

Dr Chandi Senaratne

Dr Amir Tavasoli Dr Gordon Wang

“Empowering you on the journey to mental health recovery”

Hospital Address: 29 Havelock Street, West Perth WA 6005 Phone: (08) 9481 4888 Website: www.perthclinic.com.au MEDICAL FORUM

SEPTEMBER 2017 | 29

Is it time for your financial health check?

When we examine what health of a medical practice’s accounting, we always start by asking a few simple questions, like: Are you staying up-to-date with the recent tax changes? What tax minimisation strategies do you have in place? What are your financial reporting and budgeting processes? And how do you manage your GST, income tax and payroll tax obligations?

No matter how you answer these, we always find there’s something we can help take care of.

30 | SEPTEMBER 2017

That’s because at Napoli, Chartered Accountants, we specialise in business, accounting and taxation services.

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If you’d like to chat about how we can help improve the shape of your practice, please call us on 08 6163 1888.

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guest column

Injured Workers in the Spotlight Mr Stephen Psaila-Savona, General Manager Regulatory Services within WorkCover offers suggestions to assist doctors deal with injured workers.

Doctors sometimes tell us the workers’ compensation process can feel complicated, while injured workers sometimes tell us they feel their recovery stalls when doctors don’t follow ‘return to work’ processes. Both are true! So how can we make things easier given the WA workers’ compensation and injury management scheme is big and pays about $1 billion in claims annually?

everyday workload, may be difficult. These suggestions may relieve some pressure.

The role of doctors is sequential – manage the treatment, issue Certificates of Capacity, and help develop ‘return to work’ programs.

• Eliminate barriers that prevent case conferences, which are useful to discuss a worker’s progress and any concerns.

WorkCover WA receives many calls from employers and insurers who cannot reach the worker’s doctor. Does your practice manager allow these calls to be put through to you? Have you told employers and insurers the best time to contact you?

Remember, you can charge for your time, including longer appointments to allow time for paperwork, case conferences and telephone calls. You can even request the case conference at your practice to save you travelling time.

Doctors are usually the first port of call for an injured worker who may be distressed, in pain and unsure whether they can continue working, or whether their employer supports them. These early stages can have a big impact on an injured worker’s claim and recovery.

Treating practitioners may be pressured by workers and employers to certify someone injured as ‘fit for work’ when you know they are only partially fit to do their usual duties. Also fitting in case conferences and discussions with employers and insurers, on top of your

• Certificate of Capacity templates are available online. This is the most important document in a workers’ compensation claim. Filled out accurately, it can help reduce time spent with those involved.

See the gpsupport website (gpsupport. workcover.wa.gov.au.) where explanatory notes assist you.

• Involve a Workplace Rehabilitation Provider (WRP). Are you familiar with those locally

by Medical Director Prof John Yovich

who can help injured workers? They can provide specialist support if your patient isn’t progressing as expected. You are entitled to make referrals to WRPs if you feel extra support is needed – simply document this on a Progress Certificate of Capacity and provide the recommended WRP’s details to the insurer. WorkCover WA has a list of registered WRPs on our website (workcover.wa.gov.au/healthproviders/workplace-rehabilitationproviders/) should you wish to familiarise yourself with those locally.

• Watch our videos. The WorkCover WA website hosts useful short videos that explain case conferences, return to work and injury management processes.

• Use our gpsupport website, which provides injury management strategies, templates and resources.

These suggestions help reduce the time spent on paperwork so you can spend more time helping people get better. We know we can do things better so we welcome your suggestions to make the workers’ compensation process easier (please contact communications@ workcover.wa.gov.au). The live advice line is 1300 794 744.

Specialists in Reproductive Medicine & Gynaecological Services

PIVET MEDICAL CENTRE

MOU between Curtin University and the University of Zagreb … providing cross-cultural expansion for post-Docs This year my annual pilgrimage to Europe commenced in Geneva where I attended the ESHRE (European Society for Human Reproduction and Embryology) conference.

This has become the international lead organisation in Reproductive Medicine Signing the MOU in Zagreb with Rector Prof Damir attracting more than Boras (R) and Vice Rector Prof Milos Judas (L).

12,000 delegates and with six high-ranking journals attached; one of which is RBM Online where I hold a Section Editor position.

It provided an opportunity to conduct development meetings with colleagues from around the world and we had several such opportunities to progress ideas in instrumentation, automation, NOW AT 2 LOCATIONS PERTH & BUNBURY

MEDICAL FORUM

logistics, information technology, therapeutic products and patient management strategies.

Following ESHRE, I headed to Croatia, initial home of my parents, for R&R in a warm pleasant place whilst winter prevailed in Perth. During this sojourn I acted as envoy on a diplomatic mission to complete a Memorandum of Understanding between Curtin University and the University of Zagreb, a process which commenced as an initiative from the Consul Gerant, Mladen Cvrlje in the Perth Consulate of the Republic of Croatia. This was embraced by both Institutions and enables joint research projects as well as the exchange of staff and students between the universities for specific internationally funded projects.

The MOU enables study tours as well as cross-cultural exchanges for undergraduates, post-grads and post-Docs across all academic areas.

For example Professor Mile Terziovski Dean and Professor of Innovation at Curtin Graduate School of Business has been keen to explore conjoint studies in Oil and Gas research. With respect to Medicine, I spent a day with Professor Davor Ježek, Director of the European Andrology Academy following which we plan to conduct a Workshop in Andrology in September 2018 supporting Australian delegates. Professor Ježek is also the Program Director for a full Medical Graduate course, conducted in English. On the day of my visit I witnessed 30 enthusiastic young medical students from many countries, graduate from their 5-year course. Although some Australian students have been through the course, this year was mostly represented by Canada and the USA with a very high female contingent.

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CLINICAL UPDATE

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Pharmacological treatment of stable ‘COPD’ COPD is a functional abnormality with a number of pathologies.

function, past history of asthma and sputum eosinophilia) appear to do best with ICS.

Chronic obstructive pulmonary disease (COPD) is defined as a reduction in the FEV1 to <80% of the predicted value and a reduction of the FEV1/FVC ratio to <0.7 (assuming correctly done spirometry) that is not reversible. An FEV1/FVC ratio greater than 0.7 does not exclude airflow limitation (mixed restrictive/obstructive pattern of lung function requiring full lung function testing). Considerable degrees of emphysema can exist in the presence of a normal FEV1 in some smokers.

Emphysema should be diagnosed by measurement of gas transfer and CT chest.

Therefore, it would seem beneficial to use ICS in patients with COPD who have “asthmalike” features and/or sputum eosinophilia, and to use only bronchodilators in the rest since they may be at increased of pneumonia. But how to assess sputum eosinophilia and what bronchodilators to use?

COPD – how did I get here?

The FEV1 measured in adult life is the result of cumulative lifetime events – fetal development, perinatal exposures, early childhood insults and adult exposures.

For example, the deficit in lung function associated with asthma, combined with the accelerated rate of lung function decline due to smoking, result in lower levels of lung function in later adult life than either alone (Figure 1). Stopping smoking stops the rapid decline in FEV1, within a month.

Personalised treatment applies – go for ‘GOLD’!

Pharmacological therapy in airway diseases, especially ‘COPD’ currently presents a bewildering array of options. Large-scale trials of combined therapies demonstrate modest improvements in FEV1 and quality of life and reduced exacerbation rates.

Subsequently it has been recognised that inhaled corticosteroids (ICS) use in COPD is associated with an increased risk of pneumonia and not all patients obtain benefit.

COPD patients with “asthma-like” features (e.g. allergy, reversibility/variability of lung

Take Home Points • COPD is an acronym, not a disease, which describes a functional abnormality.

• Defined by correct spirometry, COPD may result from a number of pathologies.

• Reversible and irreversible airflow obstruction may co-exist.

By C/Prof Alan James Respiratory Physician Perth

ED. COPD impacts quality of life. Optimising pharmacological treatment can be tricky.

shown to relate well to sputum eosinophils and a value >300 cells/µl (0.3 cells x 109/litre) identifies a group of patients with COPD more likely to benefit from ICS.

Fig 1: Trajectories of lung function in males from the Busselton Health Study.

Those reporting a history of asthma (generally mild to moderate) already have reduced lung function by age 18. Starting smoking around this time is associated with additional decrements in lung function over time, which if severe enough, will be called “COPD”.

Both exhaled nitric oxide and blood eosinophil levels are good predictors of sputum eosinophils. Blood eosinophil levels have been

Combinations of long-acting betaagonists (LABAs) and long-acting anti-muscarinic antagonists (LAMAs) achieves greater (modest) FEV1 improvements and quality of life outcomes than either alone. In patients with moderate fixed reductions in FEV1 it is recommended to use both, in combination. Agent choice also depends on patient convenience, ease of use and side effects which are few and usually mild. There is no evidence of superiority of the different LAMAs and LABAs when used at recommended doses. The evidencebased GOLD guidelines (2017) are recommended.

References available on request.

Author competing interests: nil relevant disclosures.

Questions? Contact the author aljames@tpg.com.au

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CLINICAL update

Patients should have their inhaler technique checked frequently - even those who have been using inhalers for years and believe they have good technique. One Australian study reported 85% of ‘confident’ inhaler users had incorrect technique.

By Ms Louise Papps Clinical Nurse Consultant Joondalup

An estimated 94% of patients have incorrect inhaler techniques increasing hospital admission risk by an estimated 50%. What are common pitfalls?

ED

• Patients frequently do not use a spacer with an MDI – a diagram depicting how a spacer improves drug deposition is a valuable resource (see image).

• Advise patients to only place one actuation into the spacer at a time.

Other common inhaler technique errors include, not exhaling prior to inhaling the medication, and failure to breath-hold post dose.

• Patients may have co-morbidities such as poor eyesight, tremor, arthritis or cognitive impairment. Once the drug type has been selected, careful selection of the appropriate device should be given, with consideration of the patients physical and cognitive capabilities (where limiting the number of devices is useful).

Demonstrating spacer use to improve symptoms.

Photo courtesy Avita Medical.

To improve adherence, most patients need to have a basic explanation of how the drugs work – the difference between preventers and relievers, and the importance of taking them appropriately to reduce symptoms and complications. Consequences of poor technique and non-adherence include increased symptoms, decreased quality of life, and increased healthcare use.

There are many stories of patients using their devices incorrectly – the following are examples I refer to when training both staff and patients.

• One patient discarded his device, and proceeded to empty the contents of a long-acting muscarinic antagonist (LAMA) capsule into his hand, before inhaling it.

• Another had not been releasing the piercing button prior to inhaling the medication (for two years), and as such the capsule was unable to spin.

The past few years have seen an influx of new devices confusing health professionals. One study demonstrated that 89% of health care professionals could not describe or demonstrate correct technique.

Many resources have been developed to assist in teaching correct inhaler technique with the various devices, such as the Lung Foundation Australia (LFA) http://lungfoundation.com.au/new-copd-patient-videosto-improve-inhaler-device-technique/ and http://lungfoundation.com.au/ health-professionals/training-and-education/. Placebos are also a useful tool to have on hand to assist in demonstrating devices.

LFA (1800 654 301 or enquries@lungfoundation.com.au ) can provide training for health professionals on inhaler device technique.

References available on request

Key messages • Check inhaler technique frequently • Ensure patients understand how inhalers and medications work.

• Practices nurses and pharmacists can assist but require training.

Author competing interests: – the author has delivered training for LFA. Questions? Contact the author 0403320117

Dr de Wet is a Clinical Haematologist with a special interest in general haematology and chronic malignant conditions including myeloproliferative disorders, myeloma, lymphoma and myelodysplasia with a focus on quality of life and supportive care.

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Improving patient inhaler technique

SEPTEMBER 2017 | 35

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Tonsillectomy in kids Tonsillectomy (with or without adenoidectomy) is one of the most common surgical procedures performed in children under age 16. The two most common indications are obstructive sleep disordered breathing and recurrent tonsillitis. Less common indications include Quinsy (peri tonsillar abscess) and suspicion of malignancy.

Tonsils and adenoids are lymphoepithelial tissues that initiate immune reactions (peak response between age two and ten) to antigens entering the body.

The American Academy of Otolaryngology (AAOHNS) provides evidence based guidance to identify children who will benefit from tonsillectomy for tonsillitis (Paradise criteria).

A child with tonsillitis should have at least seven episodes in one year or five episodes in two consecutive years or three episodes in three or more years to benefit from tonsillectomy.

Children not meeting the above criteria may still qualify for surgery due to other modifying factors that may cause considerable morbidity, including antibiotic allergy/

intolerance, febrile convulsions, growth retardation, poor school performance, enuresis and behaviour issues.

Watchful waiting is suggested for children with fewer episodes than the recommended frequency and no modifying factors.

Obstructive sleep disorder (OSD) symptoms range from simple snoring to apnoea.

OSD in children is most commonly due to adenoid and/or tonsillar hypertrophy. Growth retardation, enuresis, behaviour issues and poor school performance may also occur.

The presenting symptoms varies with age.

Polysomnography is the gold standard for assessing the severity of OSD but good history and examination will usually diagnose OSD in an otherwise healthy child.

Considerations for surgery Tonsillitis is a common presentation to GP’s resulting in antibiotic prescriptions. The costs of GP visits and antibiotic treatment can be substantial and then there are indirect costs, such as time off school and time off work for carers, to be considered.

The decision for tonsillectomy should be

By Mr George Sim Paediatric ENT Surgeon Murdoch & West Leederville shared between the ENT Surgeon and parent/ guardian. Surgical criteria, modifying factors, surgical technique, expected outcome and possible complications must be discussed in the informed consent process. Avoid elective tonsillectomy in children under age two or weighing under 12kg.

Numerous methods for tonsillectomy and/ or adenoidectomy from cold steel dissection to diathermy to radiofrequency surgery.

Children are usually admitted overnight post tonsillectomy. There are multiple co-morbidities associated with surgery, regardless of the technique used – the common issues are throat pain, haemorrhage (primary and secondary), delayed eating and voice changes.

Tonsillectomy in children aims to improve quality of life so ensure that benefits outweigh the risks and co-morbidities associated with surgery.

Further reading: see http://www.aafp.org/ afp/2011/0901/p566.html Author competing interests: nil relevant disclosures.

Questions? Contact the author on 6381 0277

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Iatrogenic Perinatal Anxiety There is an epidemic of anxiety among younger generations especially new parents, expecting to be ‘the best parent’, who believe normal is a calm compliant baby. They want something to fix their baby, stop crying, fix wind, enable sleep, and stop noises or curling up legs or vomiting. Their child has silent reflux, milk allergy, colic, tongue tie or any other condition that the parent implores us to fix. They have done research and know there is something wrong.

How can we help?

Generally, the child is thriving and the behaviour will settle as the child moves out of this developmental stage.

Begin with the assumption that the child is OK, before assuming the worst. This is exactly what we need to encourage the parents to do also. Don’t catastrophise on the first sign of something different. Babies are naturally healthy. Significant illness is rare. In order to reduce anxiety in parents, we need to encourage them to take a variation in behaviour as normal first, and only if it is very much out of the ordinary and persistent to seek an opinion.

Health professionals often feel a need to fix this ‘problem’. We are trained to look for conditions and seek solutions just like parents. The more that we look for causes and solutions, the more we encourage fearful thoughts in parents. Our desire to fix, not miss anything and show concern causes perinatal anxiety to flourish exacerbating the problem.

Our suggestion of tongue tie, leads to surgery; cow’s milk allergy leads to guilt and an extreme diet; reflux leads to medications that are not without their complications.

All our suggestions cause anxiety.

Know what is normal. If you gather a group of 5-10 babies together and observe, they feed differently, cry differently, sleep less or more, etc. There is a natural variation in behaviour not requiring a diagnosis or treatment.

Distinguish between a sick child and a healthy child whose parents have a problem. This is usually a diagnosis that can be made from a metre away. Is the baby thin, pale, unusually agitated or lethargic?

By Dr Leon Levitt General Practitioner Wembley

Parental angst might be the new black. What can we do to actually help?

ED

cannot be fixed, the greater the frustration and anxiety.

Teaching them to let go and deal with their anxiety may be the most important advice we give them for their entire parenting lives.

Consider referral to an experienced practitioner (psychologist, psychiatrist, mental health trained Child Health Nurse or GP experienced in perinatal medicine) if this is not your area.

Author competing interests: nil relevant disclosures.

Question? Contact the author on email leon@ granthamhouse.com

Spend time with the parents, educate them, reassure them, weigh the child and confirm good weight gain, and help them to let go of their frustrations. The more they try to fix a problem that is not abnormal, or one that

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MEDICAL FORUM

SEPTEMBER 2017 | 39

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Fertility, Gynaecology and Endometriosis Treatment Clinic 40 | SEPTEMBER 2017

MEDICAL FORUM

CLINICAL UPDATE

back to CONTENTs

Breathing problems: A case study CASE STUDY A 59-year-old FIFO mine site truck driver smoked 15 cigarettes per day from adolescence until five years ago. Two years ago, she developed asthma following a viral respiratory infection. Subsequent symptoms of cough, wheeze and tightness have been relieved by salbutamol MDI, used up to six times a day.

Her symptoms are not well controlled and so preventive therapy – fluticasone: salmeterol fixed dose combination – two puffs twice daily is prescribed.

Six weeks later she fell asleep driving a truck on a night shift. She has some difficulty sleeping during daytime when on night shift, denies snoring, but wakes frequently mostly with cough and takes Ventolin (2 -10 puffs of per day). She reports increasing difficulty walking upstairs at work due to shortness of breath. She takes the Seretide but misses “the occasional dose”. This time COPD is diagnosed (by a different doctor) and a long acting anticholinergic inhaler prescribed.

because she disagreed with the diagnosis of “emphysema”. When asked if there were days when she did not use Seretide, she admitted forgetting to use it most days.

quality and reduced salbutamol consumption.

Spirometry improved progressively allowing back-titration of ICS dose. LAMA was withdrawn.

Key issues:

Physicians generally overestimate their patients’ inhaler adherence rates and, even when their estimates are conservative, they are usually wrong. Non-adherence may be intentional (e.g. patient rejects diagnosis), or unintentional (e.g. poor technique). The latter is often linked to psychosocial, demographic and comorbidity factors. Both forms may be amenable to education.

Does she have asthma or COPD? Smoking 27 pack years is sufficient to cause COPD in a susceptible individual. However, symptoms in the past two years, including response to salbutamol, are consistent with asthma. Assuming correctly performed spirometry, asthma has been confirmed by objective measurement even though COPD may also be present.

Communicating the diagnosis to the patient consistently and effectively is an important prerequisite for patient engagement in asthma management, and outcome. She would benefit from formal asthma (and COPD) education partly to dispel misinformation, like the systemic effects of low-dose inhaled steroids.

Spirometry shows non-reproducible and suboptimal results on multiple attempts – low quality and non-diagnostic but maybe a clue to suboptimal inhaler use?

She has nocturnal asthma causing significant sleep disturbance, morning tiredness and daytime sleepiness (or the reverse with nightshift). Frequency of nocturnal asthma symptoms is a measure of poor control increasing the risk of severe exacerbation, time off work and mortality.

Outcome and discussion

MEDICAL FORUM

A: Assessment

Assess all medications

I: Individualisation

Individualise the regimen

D: Documentation Provide written communication E: Education

Provide accurate and continuing education tailored to the needs of the individual

S: Supervision

Provide continuing supervision of the regimen

Published estimates of adherence to inhaler therapy in asthma range from 30-70%, and is determined by many factors, including health beliefs, understanding of and attitude towards asthma, effectiveness of therapy and psychosocial factors. The professional relationship with the patient is an important factor in determining outcome, including adherence to treatment. That relationship is best viewed as a partnership (therapeutic alliance), in which there is asymmetric knowledge.

Her usage of inhaled steroids has been insufficient to control her asthma. She may have given the impression she was using her inhalers regularly, either because the appropriate question was not asked, or it was the answer the patient thought the doctor wanted.

MDI technique shows aerosol escaping from the mouth during actuation due to poor inhalation timing, pharyngeal closure or nasal inspiration – education on use of a spacer device (or DPI) would overcome this problem.

Table 1

AIDES mnemonic for improving adherence to prescribed medication (Ref: Bergman-Evans B. Geriatr Nurs 2006; 27: 174–82)

One month later she returns with cough and wheeze and was observed to use her inhaler several times, apparently with limited effect. On examination, she had bilateral inspiratory and expiratory wheeze and prolonged expiratory phase. Spirometry has deteriorated.

She demonstrates poor MDI technique with aerosol escaping from her mouth on actuation of the inhaler; inspiratory timing is poor and she appears to have nasal breathing. She stated that she uses Ventolin at about the same frequency as at the first visit, occasionally using Seretide in place of Ventolin for relief, claiming it does not work as well. She is reluctant to take Seretide because it “contains a steroid” and she had recently gained weight. She refused to use the LAMA

By Dr Michael Prichard Respiratory Physician Perth

Following education, including MDI technique and supervised trial of inhaled steroid/ LABA twice daily, regular assessment and reinforcement, she reported progressive improvement of asthma symptoms sleep

Patient communication is our responsibility.

It starts with asking the right questions such as: ‘Many patients don’t take their inhalers all the time. In the past month or two, how many days per week would you have taken your preventer inhaler?’ These are better than questions such as: ‘Do you take your asthma inhalers?’

If stated adherence is low, then nonjudgementally ask why. For example: ‘Do you have any concerns about the effectiveness of the medication, or any side effects?’, and, ‘Let’s have a look at how you use your inhaler’.

Adherence matters because those adhering to prescribed ICS/LABA inhalers have few symptoms, longer time to exacerbation, lower exacerbation rates, fewer admissions to hospital, reduced mortality and overall lower healthcare costs.

References available on request Author competing interests: – nil relevant disclosures Questions? Contact the author 9481 2244

SEPTEMBER 2017 | 41

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CLINICAL UPDATE

back to CONTENTs

Cow’s milk protein allergy in babies Affecting at least 2% of infants under age two, Cow’s Milk Protein Allergy (CPMA) may be more common due to increased real and perceived food allergy. Usually presenting within the first six months of life it appears in formula-fed and fully breast-fed infants (due to maternal dairy intake).

By Dr Christiane Remke Paediatric Allergist Nedlands

Allergies to cow’s milk protein can present with various clinical manifestations in babies, which are important to differentiate.

ED

Infants with CMP-induced enteropathy may present with diarrhoea, failure to thrive, vomiting possibly leading to hypoproteinaemia and anaemia. Onset of symptoms can be hours to days after dairy ingestion. Complete CMP avoidance is required.

Role of intolerance An intolerance to CMP can play a role in other conditions such as eczema, gastro-oesophageal reflux, infantile colic and constipation.

A carefully guided trial of (sometimes partial) eliminating dairy protein from the diet can be useful, perhaps where there is doubt, followed by a CMP challenge.

Further reading: see position papers ASCIA https://www.allergy.org.au/healthprofessionals/papers References available on request

CMPA is defined as an immunologically (IgE or non IgE mediated) adverse reaction to cow’s milk protein (CMP). The major dairy allergens are casein and/or whey proteins. Cross reactivity exists with all other mammal milks and soy milk to a lesser degree.

Accurate diagnosis is vital. Diagnostic delay may put children at risk of either acute allergic reactions or inappropriate dietary manipulations.

Immediate allergic reactions (IgE mediated) cause urticaria, erythema, angio-oedema or vomiting in up to two hours after ingestion of dairy products; anaphylaxis is a severe immediate reaction with respiratory tract involvement (coughing, wheezing, stridor) and/or hypotension. Symptoms in infants are often harder to recognise and can include severe irritability, pallor and floppiness. All affected children need to avoid CMP with provision of an appropriate substitute, an allergy action plan and, if at risk of anaphylaxis, an adrenaline auto injector. Breastfeeding mothers may have to avoid dairy in their own diet. Fortunately, most but not all children will outgrow CMPA. Non-IgE mediated conditions: Food protein induced enterocolitis syndrome typically presents with acute onset of repeated vomiting and sometimes diarrhoea leading to dehydration, hypotonia and pallor one to three hours after ingestion. Symptoms can be mistaken for gastroenteritis, sepsis or other gut disorders. Multiple presentations before the diagnosis is established are not uncommon. Acute management involves rehydration. Affected infants need to avoid all CMP. The condition often resolves before school age.

Infants with allergic proctocolitis are usually well babies presenting with low-grade rectal bleeding without other features. CMP avoidance is usually required only in the first year of life as the condition resolves.

Symptoms of eosinophilic oesophagitis can occur within hours to days and include food refusal, difficulty feeding, poor weight gain and dysphagia. Endoscopy might be required to confirm the diagnosis followed by a CMP-free diet.

Key messages • Cow’s Milk Protein Allergy has various clinical manifestations

Author competing interests – nil relevant disclosures. Questions?

Contact the author on 6389 0786

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MEDICAL FORUM

SEPTEMBER 2017 | 43

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CLINICAL UPDATE

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IPF – The game changers Idiopathic Pulmonary Fibrosis (IPF) is a usually progressive condition with median survival of only two to three years after diagnosis. Recently, two new medications (nintadinib and pirfenidone) received PBS approval. These have transformed the management. There is good evidence that these medications significantly slow the progression, reduce exacerbations and probably improve mortality outcomes with IPF. Early diagnosis and referral therefore becomes even more important.

By Dr Sina Keihani Respiratory and Sleep Disorders Physician Leeming

There are still some unanswered questions including the role of combined therapies, including anti-oxidants, as well as exact duration of therapy needed. Trials have generally been one to three years in duration.

There are new treatments for the once untreatable condition of Idiopathic Pulmonary Fibrosis

ED

Diagnosis requires exclusion of other known causes of interstitial lung disease along with recognition of a usual interstitial pneumonia (UIP) pattern. On high resolution CT, this pattern consists of subpleural lower lobe predominant reticular abnormality and honeycombing.

The multifaceted approach in management of IPF includes evidence for use of antiacid therapy and pulmonary rehabilitation.

Pulmonary hypertension is a very common comorbidity however directed treatment strategies have not proven effective and international guidelines generally recommend against their usage as well as usage of warfarin. I have found opioids to be helpful in helping severe dyspnoea and the challenging cough, when carefully titrated.

Historically, IPF was considered a chronic inflammatory disorder which gradually progressed to fibrosis. Anti-inflammatory therapy such as steroids however have proven completely ineffective. IPF is now generally regarded as a consequence of multiple interacting genetic and environmental risk factors with repetitive micro- injuries to epithelium of the alveoli leading to aberrant fibroblast propagation. Inhalation of particles such as smoking and silicates, amongst many others, have been implicated.

Nintanidib is a tyrosine kinase inhibitor inhibiting multiple receptor signal pathways implicated in fibrosis pathogenesis. Pirfenidone has anti-inflammatory and anti-fibrotic actions.

Trials have proven that both oral medications reduce the decline in vital lung capacity by around 50%. Pooled analysis form four large trials reveal possible survival advantage with pirfenidone while using nintanidib, patients experience fewer exacerbations (by around 70%). Side-effects to monitor are transaminitis with regular need for liver function testing and gastro-intestinal effects, photosensitivity (pirfenidone), bleeding (nintanidib) and diarrhoea.

Most patients should begin therapy with one of these agents at the time of diagnosis with the exception of severe cases (e.g. DLCO <30%) however there are quite a few authority requirements including confirmation of diagnosis by a multi-disciplinary team.

MEDICAL FORUM

Advanced UIP pattern: honeycombing and reticular septal thickening with subpleural and basal predominance.

However, it is tremendous to see new hope with disease modifying medication now accessible, for patients suffering with this devastating condition.

Author competing interests: nil relevant disclosures.

Questions? Contact the author on 6161 7647

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SEPTEMBER 2017 | 45

travel

Despite the naysayers Dr Carol McGrath and her sister went off to the Congo to see her beloved gorillas and it was a trip of a lifetime.

Why would you want to go to the Congo?”

“Isn’t it beset by civil war/militias/guerrilla warfare/dangerous?”

These were the encouragements from family and friends ringing in my ears when we landed in Brazzaville, capital of the Republic of Congo. This is not the all-but-failed-state of the DCR, but its small and relatively peaceful neighbour.

My sister and I are rather besotted by gorillas of the non-human variety, and visiting a remote part in the north of the country provided the opportunity to trek to see the Western Lowland Gorilla These are smaller and more arboreal cousins to those in the mountains of Rwanda and Uganda .The Western Lowland, are the ‘gorilla gorillas’ and are critically endangered.

The destination was Odzala-Kokua National Park situated in the second largest tropical rainforest in the world after the Amazon.

Our arrival was less than auspicious as the promised on-arrival visas were not available at midnight (we wondered if ever) and the luggage didn’t arrive either. After 24 hours in transit we were rescued by our meet-and-greet representative from the camps we were to visit.

Guides to the rescue Instead of sleeping on the airport floor, we were spirited off to a luxury hotel on the banks of the wide, fabled Congo river. It was a modern business hotel overlooking Kinshasa, capital of the DCR. Somewhere out there samples were being tested for Ebola from a small outbreak in the hinterland.

After several hours of extracting a visa at the airport the following morning, our charter flight departed. Flying low for two hours over endless lush and verdant forest, with wide, languid rivers interspersed, was magical.

Landing on the bumpy, grassed bush airstrip, we were collected by our guides and transferred a short distance to the first camp, Mboko, for a much-needed lunch. Then it was off to Ngaga, a lodge deep in the rainforest, within the home range of several habituated gorilla groups.

The six raffia thatched chalets, dining, lounge and bar area are all on raised decking at the top of a glade within pristine primary forest overlooking the luxuriant jungle canopy. Comfortable, quirky luxury in a remote and pristine corner of the vast Congo Basin!

46 | SEPTEMBER 2017

MEDICAL FORUM

back to CONTENTs

Breathing Heart of the Congo

travel

Pictures: Dr Carol McGrath

Science, nature, bliss The focus of the camp is the gorilla. Dr Magda Mermejo and German Ellera have been studying lowland gorillas in the Northern Congo for over 15 years and made this area around Ngaga their base because of the numbers of gorilla. Both continue to work here and guests often have the chance of meeting and discussing their research with them.There are two gorilla families – Neptuno and Jupiter – for study and tours.

Our first trek was through thick Marantaceae forest with a dense canopy of rainforest giants, bedecked with ferns, lianas and orchids.

Group size is restricted to a maximum of four guests, tracker and guide. We were fortunate to be the only guests on our walks, so it was an intimate experience.

The first sighting was of a family not more than half an hour's easy walk from the lodge along paths cleared by the secateurs-wielding guide.

They were members of the Neptuno family group and they were busy eating fruit in the trees above us. There were babies nestled in their mothers’ laps, playful adolescents

MEDICAL FORUM

and the large and intimidating silverback, Neptuno,overseeing and protecting his family.

Viewing was good, though the forest was dark, and it was with sadness we left the group when our hour was over.

A second tracking day involved a drive to the location of the second gorilla family’s overnight nest and, to our delighted surprise, they were feasting on succulent grasses by the roadside.

A unique and memorable close-up encounter!

So much to see The forest is also home to a myriad of other animals, plants, butterflies and forest walks, and with our knowledgeable guides they were fascinating, if a little humid.

The final camp was Lango, an intimate six-room lodge nestled in dense gallery forest overlooking a ‘bai’. These are grassy, swamp areas, rich in minerals and salts that attract forest elephants, sitatungas, bongos, monkeys, parrots and many waterbirds. The complex is on raised decking high enough to allow elephants to forage below and with a projecting star deck to allow magnificent views across the bai. The camp is accessed

by kayak with a short walk up stream to the lodge.

Activities here were truly immersive. Walking safaris from the camp, along crystal-clear forest streams lined with ferns, palms and dense growth – at times up to mid-chest – while being on guard not to surprise the hostile forest buffalo, skittish elephants or venomous river snakes.

As the only guests at all three camps, we enjoyed exceptional and welcoming service, sophisticated food (a fusion of local and Western cuisine) and local guides who were knowledgeable, experienced and entertaining!

The camps, which as yet are little visited, are the brainchild of German philanthropist Sabine Plattner, who has created the charity SPAC, which combines conservation, primate research, education for the local village children and vocational opportunities for these communities.

An unforgettable holiday that was also contributing to eco-conservation and the local communities!

SEPTEMBER 2017 | 47

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WINE review

By the Deep Woods and Millbrook Wines for this tasting have been chosen from Deep Woods Estate in Margaret River and Millbrook Winery in the Perth Hills. They are owned by Perth businessman Peter Fogarty as is the famous Lake's Folly in the Hunter Valley, NSW. The Deep Woods Estate needs little introduction. It is an award-winning estate established in 1997 and purchased by the Fogarty family in 2005. It is one of the highest vineyards in the region, situated in Yallingup at the northern end of the region where it benefits from the moderating influence of the Indian Ocean.

Millbrook is an attractive property with a beautiful winery and restaurant and is an ideal day trip from the Perth suburbs. It draws on fruit from surrounding vineyards and other regions producing both the estate wines and a regional series. The estate grown Viognier varietal wines (not reviewed) have been a particular fascination of mine and I firmly believe they are the best examples of this unique variety produced in Australia.

By Dr Craig Drummond Master of Wine

REVIEWER'S

1

2

3

PICK

Millbrook Winery Estate 2014 Shiraz Viognier (RRP $35)

This is my pick of the tasting.

The Shiraz has the addition of 3% Viognier a tradition practised in the great wines of Cote Rotie and Hermitage in the Northern Rhone Valley. One might wonder what such a small addition could add – well it gives an aromatic lift, a little softness to the palate and enhanced colour. This wine is a beauty, Wonderful aromas of violets and allspice.

The mouthfeel is supple, smooth and refined and the black cherry, aniseed and liquorice go on and on.

A complete wine with 'personality'. It’s difficult not to drink now, but will reward cellaring for a couple of decades.

4

1. Deep Woods Estate 2017 Margaret River Harmony Rose (RRP $15) Made from Shiraz and Tempranillo, this is a fruity, fresh style made for early drinking. It displays an attractive magenta colour, a ‘pretty’ nose with lively red fruits, strawberry dominating. The palate is clean, linear and uncomplicated. Evident acid holds it all together with the fruit sweetness giving a lift to the finish. It will be a good luncheon wine when summer arrives.

3. Deep Woods Estate 2014 Margaret River Cabernet Sauvignon (RRP $35) Made from select parcels of fruit from 30-year-old-vines and matured in new and seasoned French barriques. It is a great example of this Margaret River flagship red variety. The nose is complex, rich and enticing with blackberry and camphor while the palate has cassis, black cherry and some bitter chocolate. Tannins fine grained and drying. Smooth, ripe and integrated, this wine really lingers. It will drink well for a further 20 years.

2. Deep Woods Estate 2016 Margaret River Chardonnay (RRP $20) This appealing wine is naturally fermented and given six months yeast lees contact and seasoned in French oak. It has beguiling aromas of stone fruit and nashi pear, with subtle nutty oak showing through. The palate has structural definition from acid and mineral elements and flavours of stonefruit, melon and cashew. The oak is not overt and well integrated. There has been some steel-vat time to give a focused 'Chablis-like’ character. Easy to drink now, but could be enjoyed for another few years.

4. Millbrook Winery 20116 Tempranillo (RRP $28) One of Millbrook's ‘regional’ wines, it is made from fruit from the Geographe region. This Spanish variety is becoming increasingly popular in Australia and this wine is one of the better examples I have tasted. Tempranillo can be made in a variety of styles, from light-bodied to full-bodied – Millbrook’s is a medium-to-full-bodied style, showing garnet colour, with spicy black fruits and complex savoury elements on the nose with flavours of ripe mulberry and blackberry. It has a lush texture with a slight milky character (but not to the extent that typifies the famous wines of Rioja in Spain).

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SEPTEMBER 2017 | 49

Doctor in the Arts

A Room of His Own

An imaginative space is vital for a fiction writer, and Dr Robert Edeson loves living there!

There are many different ways to ease into retirement and writing novels is just one of them. A consultant anaesthetist in a former life, Rob Edeson has penned two works of fiction and his latest, From Bad to Worse, has just hit the shelves.

“I’d describe it as a vendetta novel, but the actual genre is a little more slippery. My books have been labelled as ‘Literary Fiction’ and a ‘Literature of Ideas’ and I’m happy with both of those.”

One of the common threads in both The Weaver Fish (Rob’s first novel) and Bad to Worse is humour. There are genuine ‘laugh out loud’ moments, albeit delightfully esoteric in nature.

“I write with the intention of amusing myself and a particular friend of mine. But I also hope there are lots of other people who share an interest in the themes.

I certainly wouldn’t say that I write for a specific audience.”

“It was very pleasing to hear that the publisher thought the book was ‘commercial’. The sales haven’t been huge but Fremantle Press hasn’t lost money, and for that I’m happy. They’re a notfor-profit organisation and terrific to work with. My editor, Georgia Richter has been absolutely wonderful!”

“I’ve developed a great relationship with all of them.”

Welcome to the world “I often joke about truckloads of royalty payments being dumped in front of our home but that hasn’t happened quite yet.

Although, the World Rights for Bad to Worse have been purchased by a London publisher and I received a generous advance, which was nice.”

“And that means the book will be published in the UK with a new cover and will also be distributed in the USA.” Robert shies away from the descriptor, ‘difficult’ being applied to his novels.

Nonetheless, the writing is laced with complex scientific and mathematical theorems complete with endnotes, appendices and an index. It all makes for an interesting mix. Bad to Worse opens

with a distinctly amusing ‘Spaghetti Western’ scene and, later in the book, there’s a riveting, dramatic and erudite discussion on the spatial dynamics of a rolling ship on a wild ocean.

“I always thought it’d be fun, as an Australian, to write a ‘Western’ and, in this case, it does set the raison d’etre of the ‘vendetta’ narrative. Much of the content in that first chapter returns later in the story. And behind that rather parodic opening sits the motif of the changing nature of the main character, Richard Worse.”

“It’s both comedic and cinematic, and I like that.”

“I’m also rather fond of Richard Worse, as are many of my readers. And women seem to love him! He’s a highly moral and thoroughly ethical character and I might take that further in the next book. Perhaps as some sort of invincible ‘hero’ who achieves that status by being intrinsically ‘clever’?

Bridge over the divide It’s probably drawing a long bow to say that Robert Edeson is, almost single-handedly, attempting to redress the schism between Science and the Arts so eloquently posited in C.P. Snow’s Two Cultures, but he’s giving it a damn good go!

“I’m very lucky to have a facility with language and a strong interest in the ‘hard’ sciences.

I’ve always been like that since my schooldays at Christchurch. As a medical student I wrote some absurdist stuff, mainly to amuse myself. And then, later on, to entertain my partner (Dr Lindy Roberts, see MF, Feb 2017 Film Noir).”

“It’s interesting, too, because some of the ideas I was tossing around in those early days have reappeared in Weaver Fish and Bad to Worse. These certainly aren’t ‘ordinary’ novels and it’s fair to say they will, at times, test the credulity of the reader.”

Taking on the task of writing a novel is, as Robert says, a ‘big picture’ undertaking. It’s not for the faint-hearted and work just gets in the way.

“It was difficult finding time to write as a full-time consultant anaesthetist because you don’t have time to allow your imagination some much-needed space. It’s a stressful job, being an anaesthetist.”

“I’m incredibly lucky. The week I stopped working I won the Hungerford Award, which facilitated the publication of my first novel. I feel that almost everything I’ve done in life has been leading towards writing these books.”

“I’m the happiest I’ve ever been, intellectually and in other ways.”

By Peter McClelland

MEDICAL FORUM

MUSIC

Swoon to Their Toons

Mr Music Paul Grabowsky and chanteuse Kate Ceberano combine their magic in a show all about love.

He’s the musical polymath who composed the score for the opening ceremony of the Sydney 2000 Olympic Games, played with some of the jazz greats in Europe and he’s on his way to Perth. Paul Grabowsky, with songstress Kate Ceberano, is bringing Love Songs to His Majesty’s Theatre on October 6 for a night of ‘stripped back and reimagined’ classics.

“It’s going to be a lot of fun doing the show with Kate. We’ve both go a long way, right back to the early 1980s when we performed together in Melbourne’s jazz scene. We’re good friends and that makes it much easier to create a sense of intimacy with the audience, particularly when we’re playing music that means so much to both of us.”

“Kate is a very generous person onstage and she really knows how to take the audience along with her on a musical journey.”

As a young boy there was always music in the Grabowsky home and Paul readily concedes he couldn’t live without it.

“A world without music would be an awful place to live and it’s been a big part of my life for as long as I can remember. My father was a musician, although not a professional one, and we always had music in the house.

My brother plays music for a living, too.”

“In the early days I played a lot in both Europe and New York, in fact I did some classes at the Juilliard School. But the majority of my musical education was in Melbourne at the Conservatorium. There were some wonderful young musicians there who went on to have terrific careers.”

The list of Paul’s musical interests is a long and eclectic one, ranging from playing jazz with Art Farmer and Chet Baker to the Hush program in children’s hospitals all around Australia.

“I guess I’ve inherited some of my father’s restlessness, he was a self-taught engineer and pilot and did some amazing things in New Guinea. I’m also endlessly curious about the world and music is my medium to explore life.”

“It’s really wonderful to be able to apply the language of music to all kinds of different situations. I know I’m approaching the magic 60 years, but I honestly feel that my best creative years are ahead of me. That’s one of the good things about music, you MEDICAL FORUM

can keep doing it right into your old age and it has the added benefit of keeping your brain agile as well.”

“I became involved in the Hush program after our son was ill and had a stint in hospital. We wanted to do something that would improve the ambience in a hospital environment because they can be pretty intimidating places for young children – and their parents, too!”

A long career as a professional musician can take its toll and Paul hasn’t emerged totally unscathed.

“I haven’t had any RSI issues but playing piano does put a bit of pressure on the shoulders and the finger muscles. I’ve always tried to stay really ‘centred’ when I’m playing and maintain that core strength in the solar plexus region.”

“But I do have problems with tinnitus due to some of those high frequencies you get in jazz. Those big clashes of cymbals aren’t great! The ringing in my ears isn’t crippling.

I’m aware it’s there but it doesn’t bother me too much.”

Paul is looking forward to returning to Perth and gives a glimpse of the Love Songs concert.

“We’ll be playing music that Kate and I both enjoy and we’re sure that the audience will get a sense of that. I hope that when the curtain comes down and people wend their way home they’ll take some memories of these beautiful songs with them.”

By Peter McClelland SEPTEMBER 2017 | 51

theatre

I Am My Own Wife In 1928, the world welcomed an extraordinary character into its ranks.

Charlotte Von Mahlsdorf, who was born the boy, Lothar Berfelde, to Max Berfelde and Gretchen Gaupp in Berlin-Mahlsdorf, Germany, arrived determined almost instantly to set society mores on their head.

Her father was a high-ranking Nazi who beat his wife and child until the 14-year-old dress-wearing Charlotte struck the back of his head with a kitchen implement (some say rolling pin, others say ladle) killing Max in three blows.

In many ways this is the most conventional part of Charlotte’s life. What is astounding is how this young person, so committed to being the individual she was, withstood the repressions of not only the Nazis but also the Communists who took over East Berlin in 1945.

This fascinating story was taken on by American playwright Doug Wright whose play, I Am My Own Wife, has won a string of awards including the Pulitzer and Tony.

Beer

Winner

Next month Black Swan State Theatre Company mount this play, the title of which comes from an intended inscription of a statue of Charlotte. However her family rejected it.

Brendan Hanson has been preparing the solo show since the beginning of the year, which adds an even greater sense of epic to a production in which he has to portray 36 characters with accents.

But versatility is his middle name! In October 2015, Medical Forum spoke to Brendan on the eve of his turn in another Pulizer Prize winning play, the contemporary opera Next to Normal about a woman revealing her mental unravelling to the world. Last year his seriously perverted portrayal of a leatherclass Newt Gringich in Clinton the Musical, bare bottom and all, was literally a sight to behold. And in between he teaches opera students acting and improvisation and works both as director and teacher for WA Opera So taking on Charlotte von Mahlsdorf and the 35 other characters that are needed to tell this story should come as no real surprise.

The winner of the mixed Cooper’s Dozen is Dr Rose Schuddinh. She and husband, Alan, have their first baby looming and, until that happy event, it will be Alan enjoying the spoils. In fact, Rose told Medical Forum that he planned to open a bottle or two while watching the Wallabies battle the All Blacks.

The beer was good, but the result was not so wonderful.

“I consider myself lucky to be an artist who tells amazing stories. If people want to keep working with me to tell incredible stories, it’s as the Chinese say, double lucky,” he said.

“I feel fortunate to have such diversity of my career. To be honest, I have the attention span of a gnat. I need to teach and to act, to sing and to dance and then do a straight play.

I love a challenge.”

Brendan admits that I Am My Own Wife is a project he needs to be well-prepared for.

“With 80 pages and 36 characters all with accents, it has been a huge amount of work and it would have been impossible to pull off with the usual four-week rehearsal period.”

Charlotte, at 14, escaped a firing squad for refusing to join the Hitler Youth. At 16, she was imprisoned for killing her father, but only after several months being locked up in a mental institution. When she was freed at the Liberation of Berlin, she began her life as a woman, constructing a life while the country was reconstructed all around her.

So what effect has 36 characters floating around in his head have on Brendan Hanson’s life?

“I feel flexible! I spend so much time in the minds of so many people who are all so different – from her brutal father to gentler others. It’s really wild to develop that kind of mercurial energy. As an actor I’m used to inhabiting the clothes of just one character and learn to live with them, but this is different. In this instance I’m finding a lot of qualities in myself rather than finding myself fully immersed into others’ lives.”

“While it has been a long and protracted process, it has also been absolutely fascinating. I will be really interested to see and feel its effect on an audience.”

By Jan Hallam 52 | SEPTEMBER 2017

MEDICAL FORUM

Competitions

FEATURE

COMP

Entering Medical Forum's competitions is easy!

Simply visit www.medicalhub.com.au and click on the ‘Competitions’ link to enter.

Kids Theatre: Horrible Harriet Leah Hobbs’ much-loved anti-heroine Horrible Harriet leaps off the page and onto the stage of the Heath Ledger Theatre in October bringing her unique view of the world to the kids of WA. Horrible Harriet lives in the roof of her school and keeps teachers chained in the cellar doing her homework.

So far – legendary! Then some newbies arrive on the scene.

Blade Runner 2049 Ryan Gosling is the new LAPD Blade Runner, K, in this sequel to the 1982 cult classic.

Thirty years after the events of the first film, LAPD Officer K (Ryan Gosling) unearths a long-buried secret that has the potential to plunge what’s left of society into chaos.

K’s discovery leads him on a quest to find Rick Deckard (Harrison Ford), the former LAPD blade runner who has been missing for 30 years. It is directed by Denis Villeneuve and will also feature the talents of Robin Wright (House of Cards) and Jared Leto.

The original Blade Runner, based on the Philip K. Dick’s novella, Do Androids Dream of Electric Sheep? and directed by Ridley Scott, set imaginations racing about a world of flying cards, androids that look and behave like humans and policemen whose job it is to not let them rule the world. It seemed so far away in 1982!

This sequel is highly anticipated.

In cinemas, October 5

Movie: Final Portrait

The life and times of celebrated Swiss sculptor Alberto Giacometti hits the big screen with Geoffrey Rush playing the lead role. The sculptor is famous for his elongated human figures which were wondered at during his lifetime but has gone on to international fame since his death in 1966.

In Cinemas, Ocobert 5

Movie: Home Again A woman moves to LA with her young daughters after her marriage breaks down and finds a ragtag bag of young filmmakers who move in with her.

Life twists and turns in unexpected ways but the party ends when her husband shows up, suitcase in hand.

In cinemas, October 19

Theatre: I Am My Own Wife

Calculating Risk PTSD & First Responders Business of Medicine Prostate Surveillance

J U LY 2 0 1 7

Movie – Valerian and the City of A Thousand Planets: Dr Mandy Croft, Dr Moira Westmore, Dr Kylie Seow, Dr Stuart Paterson, Dr Derek Johns, Dr David Graham, Dr Prani Shrivastava, Dr Edmund Olszewski, Dr Susan Sparrow, Dr Richard John

M E DIC AL FO RU M $12 .50

Winners from July

Heath Ledger Theatre, Oct 14-19; MF show family pass (4 tickets), Noon, Saturday, Oct 14

Movie – The Trip to Spain: Ms Karen Fairhead, Dr Peter Bray, Dr Annette Finn, Dr Alastair Currie, Dr Kate Concanen, Dr Caroline Chin, Dr Anthony Stroud, Dr Sarah Chisholm, Dr Alem Bajrovic, Dr Simon Turner Major Sponsor

Live Event – The Dark Tower: Dr Cathy Kan, Dr Claire Armanasco, Dr Esther Moses, Dr Lin Arias, Dr Michael Parola, Dr David Storer, Dr Andrew Christophers, Dr Brett Baird, Mr Pete Matheos, Mr Ray Barnes

July 2017

www.mforum.com.au

The extraordinary life of German antiquarian Charlotte von Mahlsdorf, who was born Lothar Berfelde, goes under the microscope. In prison for murdering her father when she was just 12, Charlotte survived the Nazi and Communist regimes in plain sight as a transvestite. A Pulitzer Prize and Tony Award winner that will have you talking.

Studio Underground, State Theatre Centre, Oct 12-29

Music – Simone Young & 20 Years With WASO: Dr Lee Jackson Theatre – 1984: Dr Ruby Chan Theatre – Bell Shakespeare’s Merchant of Venice: Dr David Jameson Winners from June Movie – Hampstead: Dr Emma Kempster, Dr Jen Buelow, Dr Michel Hung, Dr Melanie Chen, Dr Jenny Phillip, Dr Stanley Khoo, Dr May-Ann Ho, Dr Hilary Clayton, Dr Bibiana Tie, Dr Colin Lau

Music: Love Songs Two of Australia’s best contemporary musicians, jazz maestro and all-round polymath Paul Grabowsky and singer Kate Ceberano, present a tribute to love in all its musical forms. From The Carpenters and Burt Bacharach to Hoagy Carmichael and the French school led by Sati and Legrand, they will have you swooning.

His Majesty's Theatre, October 6

MEDICAL FORUM

SEPTEMBER 2017 | 53

leisure

MY LOCAL

Duck Duck Bruce Café (BYO) 18 Collie St, Fremantle Ph 6219 5216 www.duckduckbruce.com.au There’s a really nice ambience to the place, particularly in the courtyard but inside is pretty funky as well. It’s a great place for both breakfast and lunch with lots of interesting ingredients such as pomegranate, sumac and preserved lemon. The menu is pretty eclectic and less adventurous ‘egg and bacon’ dishes are relegated to the bottom of list.

Really appealing was All About Greens and Grains – a Hug on the Inside. They also have a killer granola with a mango and cardamom kulfi called, She’ll Be Apples.

The coffee is terrific, as is the wonderful and super-friendly staff.

Most dishes are in the $16-$22 price-range. Go there, you’ll love it!

The cabby and the nun A cabby picks up a nun and when she gets into the cab, the cab driver won't stop staring at her.

She asks him why he is staring and he replies sheepishly, “Well, I've always had a fantasy to have a nun kiss me.”

A taste of your own medicine A veterinarian was feeling ill and went to see her doctor. The doctor asked her all the usual questions, about symptoms, how long had they been occurring, etc., when she interrupted him: "Hey look, I’m a vet - I don’t need to ask my patients these kind of questions: I can tell what’s wrong just by looking. Why can’t you?" The doctor nodded, looked her up and down, wrote out a prescription, and handed it to her and said, "There you are. Of course, if that doesn’t work, we’ll have to have you put down."

Divorce drunkenness A couple are dining in a fancy restaurant, and the husband keeps staring at a drunken lady swigging her gin as she sits alone at a nearby table, until the wife asks, "Do you know her?"

“Well, ok,” says the nun. “But I have two rules: you have to be single and you have to be Catholic.”

The cab driver is very excited and says, “Yes, I am single and I'm Catholic too!”

“Ok,” the nun says and she fulfils his fantasy with a kiss that would make a hooker blush.

Suddenly the cabby starts crying.

“My dear child,” says the nun, “why are you crying?”

“Forgive me sister, but I have sinned. I lied, I must confess, I'm married and I'm Jewish.”

“That's Ok,” says the nun. “My name’s Kevin and I'm on my way to a fancy dress party!”

"Yes," sighs the husband, "She's my ex-wife. She took to drinking right after we divorced seven years ago, and I hear she hasn't been sober since."

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